Basic Information
| Provider Information | |||||||||
| NPI: | 1437150927 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | CHANDAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG B | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3799131889 | ||||||||
| FaxNumber: | 3722398119 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 OVERBROOK DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MONROE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450503101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135397356 | ||||||||
| FaxNumber: | 5135397782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 72286 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2019121 | 05 | OH | MEDICAID |