Provider Demographics
NPI:1124005863
Name:GUPTA, MANISH R (DO)
Entity Type:Individual
Prefix:DR
First Name:MANISH
Middle Name:R
Last Name:GUPTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 ISAAC STREETS DR
Mailing Address - Street 2:SUITE 136
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3291
Mailing Address - Country:US
Mailing Address - Phone:419-696-5656
Mailing Address - Fax:419-844-8784
Practice Address - Street 1:1050 ISAAC STREETS DR
Practice Address - Street 2:SUITE 136
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3291
Practice Address - Country:US
Practice Address - Phone:419-696-5656
Practice Address - Fax:419-844-8784
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-6763-G2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2492922Medicaid
I08513Medicare UPIN
OHGU4138421Medicare ID - Type Unspecified