Basic Information
| Provider Information | |||||||||
| NPI: | 1750497277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | BHAGWAN | ||||||||
| MiddleName: | DASS | ||||||||
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| Credential: | MD FACC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 81 HIGHLAND AVE | ||||||||
| Address2: | NORTH SHORE HEALTH SYSTEMS | ||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783544173 | ||||||||
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| Practice Location | |||||||||
| Address1: | POST OFFICE SQUARE LYNNFIELD MED BLDG | ||||||||
| Address2: | |||||||||
| City: | LYNNFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815990594 | ||||||||
| FaxNumber: | 7815816540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 01/18/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 44639 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 44639 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 9738894 | 05 | MA | MEDICAID |