Provider Demographics
NPI:1780653154
Name:GUPTA, ANJAN (MD)
Entity Type:Individual
Prefix:
First Name:ANJAN
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 2040
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-2040
Mailing Address - Country:US
Mailing Address - Phone:414-649-3370
Mailing Address - Fax:414-649-3278
Practice Address - Street 1:6847 N CHESTNUT ST STE 100
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3929
Practice Address - Country:US
Practice Address - Phone:330-297-6110
Practice Address - Fax:330-296-0592
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37401207RC0000X
WI37401-020207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32278400Medicaid
WI000740245Medicare PIN
000704130Medicare PIN
G32680Medicare UPIN
WI000760350Medicare PIN
WI32278400Medicaid
WI000754475Medicare PIN