Basic Information
| Provider Information | |||||||||
| NPI: | 1912298381 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | NIKHIL | ||||||||
| MiddleName: | KUMAR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 MEDICAL PARK DR STE 10 | ||||||||
| Address2: | |||||||||
| City: | WEST NYACK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109941966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453545000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2 MEDICAL PARK DR STE 10 | ||||||||
| Address2: | |||||||||
| City: | WEST NYACK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109941966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453545000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2011 | ||||||||
| LastUpdateDate: | 07/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 303415 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 036141335 | 05 | IL | MEDICAID |