Provider Demographics
NPI:1326182015
Name:GUPTA, GOPAL N (MD)
Entity Type:Individual
Prefix:
First Name:GOPAL
Middle Name:N
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 1:2160 S 1ST AVE
Mailing Address - Street 2:FAHEY CENTER, BLDG 54
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-5098
Mailing Address - Fax:708-126-1699
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:FAHEY CENTER, BLDG 54
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-5098
Practice Address - Fax:708-126-1699
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036128866208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology