Provider Demographics
NPI:1942352547
Name:GUPTA MEDICAL CLINIC LTD
Entity Type:Organization
Organization Name:GUPTA MEDICAL CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANJEEV
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-459-8240
Mailing Address - Street 1:284 MEMORIAL CT STE B
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6231
Mailing Address - Country:US
Mailing Address - Phone:815-459-8240
Mailing Address - Fax:815-459-8470
Practice Address - Street 1:284 MEMORIAL CT STE B
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6231
Practice Address - Country:US
Practice Address - Phone:815-459-8240
Practice Address - Fax:815-459-8470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100728207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID