Shivane K Gupta, MD

Primary specialty

Oral & Maxillofacial Surgery (D.M.D.)Taxonomy code 204E00000X

License

078309 Issued in GA

Practice address

4150 Five Forks Trickum Rd SW Ste 1
Lilburn, GA 30047-3130

Phone

(770) 717-7225

Fax

(770) 717-7228

NPI assigned

Jun 24, 2010

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1277337600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1657065600000",
    "number": "1295046399",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4150 FIVE FORKS TRICKUM RD SW STE 1",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "300473130",
            "telephone_number": "770-717-7225",
            "fax_number": "770-717-7228"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4150 FIVE FORKS TRICKUM RD SW STE 1",
            "city": "LILBURN",
            "state": "GA",
            "postal_code": "300473130",
            "telephone_number": "770-717-7225",
            "fax_number": "770-717-7228"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GUPTA",
        "first_name": "SHIVANE",
        "middle_name": "K",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2010-06-24",
        "last_updated": "2022-07-06",
        "certification_date": "2022-07-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "204E00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Oral & Maxillofacial Surgery",
            "state": "GA",
            "license": "078309",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Oral & Maxillofacial Surgery (D.M.D.) in Lilburn, GA
• Providers in Lilburn, GA by specialty
• Oral & Maxillofacial Surgery (D.M.D.) in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 6, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.