Provider Demographics
NPI:1871729210
Name:GUPTA, ACHAL (MD)
Entity type:Individual
Prefix:
First Name:ACHAL
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 VOYAGER DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8303
Mailing Address - Country:US
Mailing Address - Phone:715-644-5530
Mailing Address - Fax:
Practice Address - Street 1:1120 PINE ST
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:WI
Practice Address - Zip Code:54768-1297
Practice Address - Country:US
Practice Address - Phone:715-644-5530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-29
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54799-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI54799OtherWI MEDICAL LICENSE