Provider Demographics
NPI:1407844517
Name:GUPTA, SAMIR K (MD)
Entity Type:Individual
Prefix:
First Name:SAMIR
Middle Name:K
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 1:333 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-8200
Mailing Address - Country:US
Mailing Address - Phone:815-725-7222
Mailing Address - Fax:815-725-7080
Practice Address - Street 1:333 MADISON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8200
Practice Address - Country:US
Practice Address - Phone:815-725-7222
Practice Address - Fax:815-725-7080
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094940207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094940Medicaid
ILH09175Medicare UPIN
IL036094940Medicaid