Provider Demographics
NPI:1114182771
Name:GUPTA, SANDHYA (MD)
Entity Type:Individual
Prefix:
First Name:SANDHYA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:262-741-2718
Mailing Address - Fax:
Practice Address - Street 1:W3985 COUNTY ROAD NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4337
Practice Address - Country:US
Practice Address - Phone:262-741-2718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54045207R00000X, 208M00000X
IL125-055483207R00000X
VA0101262802208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100011729Medicaid