Provider Demographics
NPI:1528023561
Name:GUPTA, AMITAVA (MD)
Entity Type:Individual
Prefix:
First Name:AMITAVA
Middle Name:
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:315 E BROADWAY
Practice Address - Street 2:STE 195
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1703
Practice Address - Country:US
Practice Address - Phone:502-629-4263
Practice Address - Fax:502-629-4282
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30598207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2734973000OtherPASSPORT ADVANTAGE - LAH
KY50011055OtherPASSPORT - LAH
KY00023026OOtherHUMANA - LAH
KY64305980Medicaid
KY000000507565OtherANTHEM - LAH
KYP00389564OtherRAILROAD MEDICARE
IN100139950Medicaid
KY0733812OtherCIGNA - LAH
KY072694OtherSIHO - LAH
KYP00389564OtherRAILROAD MEDICARE
KYF841160Medicare UPIN
KY0998835Medicare PIN