Provider Demographics
NPI:1790749612
Name:GUPTA, GEETA (MD)
Entity Type:Individual
Prefix:
First Name:GEETA
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 1:1054 MARTIN LUTHER KING DRIVE
Mailing Address - Street 2:SUITE125
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801
Mailing Address - Country:US
Mailing Address - Phone:618-532-1155
Mailing Address - Fax:618-532-1117
Practice Address - Street 1:1054 MARTIN LUTHER KING DRIVE
Practice Address - Street 2:SUITE125
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801
Practice Address - Country:US
Practice Address - Phone:618-532-1155
Practice Address - Fax:618-532-1117
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD93819Medicare UPIN
ILD93819Medicare ID - Type Unspecified
IL648180Medicare ID - Type UnspecifiedPRO #