Basic Information
| Provider Information | |||||||||
| NPI: | 1073729125 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | GARIMA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W 22ND ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605231563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305755000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11104 PARKVIEW CIRCLE DR STE 330 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604715114 | ||||||||
| FaxNumber: | 2604175507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 35.098119 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 01066542A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 00246075 | 05 | NY | MEDICAID |