Provider Demographics
NPI:1609908383
Name:GUPTA, RENU (MD)
Entity Type:Individual
Prefix:DR
First Name:RENU
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:RENU
Other - Middle Name:
Other - Last Name:GARG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1221 LONGFORD ST
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-7748
Mailing Address - Country:US
Mailing Address - Phone:630-910-0683
Mailing Address - Fax:630-910-0685
Practice Address - Street 1:1221 LONGFORD ST
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-7748
Practice Address - Country:US
Practice Address - Phone:630-910-0683
Practice Address - Fax:630-910-0685
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-084024207Q00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02221309OtherBLUE CROSS BLUE SHIELD
IL036084024Medicaid
IL02221309OtherBLUE CROSS BLUE SHIELD