Basic Information
| Provider Information | |||||||||
| NPI: | 1770087231 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | PAVAN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12251 S 80TH AVE | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089234000 | ||||||||
| FaxNumber: | 7089235859 | ||||||||
| Practice Location | |||||||||
| Address1: | 12251 S 80TH AVE | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089234000 | ||||||||
| FaxNumber: | 7089235859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2018 | ||||||||
| LastUpdateDate: | 05/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 036154454 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 036154454 | 05 | IL | MEDICAID |