Provider Demographics
NPI:1760583629
Name:GUPTA, VANITA (MD)
Entity Type:Individual
Prefix:
First Name:VANITA
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 1:87 N AIRLITE ST STE 130
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4991
Mailing Address - Country:US
Mailing Address - Phone:847-888-3661
Mailing Address - Fax:847-888-9964
Practice Address - Street 1:87 N AIRLITE ST STE 130
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4991
Practice Address - Country:US
Practice Address - Phone:847-888-3661
Practice Address - Fax:847-888-9964
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114356207VX0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4532532OtherBLUE CROSS BLUE SHIELD
IL036114356Medicaid
IL216065Medicare PIN