Provider Demographics
NPI:1013938257
Name:GUPTA, ANUJA (MD)
Entity Type:Individual
Prefix:
First Name:ANUJA
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 1:1905 W COURT ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3163
Mailing Address - Country:US
Mailing Address - Phone:815-935-7256
Mailing Address - Fax:
Practice Address - Street 1:500 N WALL ST
Practice Address - Street 2:SUITE 100
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2942
Practice Address - Country:US
Practice Address - Phone:815-933-2557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2004-07582080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK46407Medicare UPIN