Basic Information
Provider Information | |||||||||
NPI: | 1124095823 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUPTA | ||||||||
FirstName: | MADHUKAR | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4380 MALSBARY RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452425644 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5133664488 | ||||||||
FaxNumber: | 5133664480 | ||||||||
Practice Location | |||||||||
Address1: | 11140 MONTGOMERY RD | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452492309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5137927800 | ||||||||
FaxNumber: | 5137927807 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2006 | ||||||||
LastUpdateDate: | 10/24/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/24/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35083146 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | 35083146 | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
ID | Type | State | Issuer | Description | 000000310785 | 01 |   | ANTHEM | OTHER | 283830 | 01 |   | AMERIGROUP | OTHER | 2435805 | 05 | OH |   | MEDICAID | 64088099 | 05 | KY |   | MEDICAID | 1519679400 | 01 |   | WORKMANS COMP | OTHER | 2503778 | 01 |   | UNITED | OTHER | 200503740 | 05 | IN |   | MEDICAID |