Basic Information
| Provider Information | |||||||||
| NPI: | 1780653154 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUPTA | ||||||||
| FirstName: | ANJAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2040 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532012040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146493370 | ||||||||
| FaxNumber: | 4146493278 | ||||||||
| Practice Location | |||||||||
| Address1: | 6847 N CHESTNUT ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | RAVENNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442663929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302976110 | ||||||||
| FaxNumber: | 3302960592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 12/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 37401 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 37401-020 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 32278400 | 05 | WI | MEDICAID |