Provider Demographics
NPI:1861679813
Name:PRAVIN GUPTA M.D., P.C.
Entity Type:Organization
Organization Name:PRAVIN GUPTA M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-836-0031
Mailing Address - Street 1:900 RIDGE RD
Mailing Address - Street 2:STE L
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1726
Mailing Address - Country:US
Mailing Address - Phone:219-836-0031
Mailing Address - Fax:219-836-0051
Practice Address - Street 1:900 RIDGE RD
Practice Address - Street 2:STE L
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1726
Practice Address - Country:US
Practice Address - Phone:219-836-0031
Practice Address - Fax:219-836-0051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039588207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INE24429Medicare UPIN