Provider Demographics
NPI:1205044062
Name:GUPTA, POOJA (MD)
Entity Type:Individual
Prefix:DR
First Name:POOJA
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 1:900 MAIN ST STE 630
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-5024
Mailing Address - Country:US
Mailing Address - Phone:309-672-4433
Mailing Address - Fax:
Practice Address - Street 1:880 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3409
Practice Address - Country:US
Practice Address - Phone:901-545-6969
Practice Address - Fax:901-545-4748
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006013138207R00000X
NE6462207RP1001X
TN66968207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036123061OtherLICENSE