Provider Demographics
NPI:1215030481
Name:GUPTA, MADAN L (MD)
Entity Type:Individual
Prefix:
First Name:MADAN
Middle Name:L
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 N SEMINARY ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-1251
Mailing Address - Country:US
Mailing Address - Phone:309-344-1000
Mailing Address - Fax:309-344-1054
Practice Address - Street 1:3315 N SEMINARY ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1251
Practice Address - Country:US
Practice Address - Phone:309-344-1000
Practice Address - Fax:309-344-1054
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
364271985-10OtherJOHN DEERE
4815127OtherBC/BS
0581348OtherACS
10589098OtherCAQH
4319343OtherAETNA
938220Medicare ID - Type Unspecified
C37237Medicare UPIN
4815127OtherBC/BS
364271985-10OtherJOHN DEERE