Provider Demographics
NPI:1437150927
Name:GUPTA, CHANDAN (MD)
Entity Type:Individual
Prefix:
First Name:CHANDAN
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 1:3170 KETTERING BLVD BLDG B
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:379-913-1889
Mailing Address - Fax:372-239-8119
Practice Address - Street 1:20 OVERBROOK DR
Practice Address - Street 2:SUITE C
Practice Address - City:MONROE
Practice Address - State:OH
Practice Address - Zip Code:45050-3101
Practice Address - Country:US
Practice Address - Phone:513-539-7356
Practice Address - Fax:513-539-7782
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH72286207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2019121Medicaid
OHH222740Medicare PIN
OHG73153Medicare UPIN
OH2396312Medicaid