Provider Demographics
NPI:1023177128
Name:GAUTAM GUPTA
Entity type:Organization
Organization Name:GAUTAM GUPTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:GAUTAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-229-1899
Mailing Address - Street 1:6090 STRATHMOOR DR
Mailing Address - Street 2:SUITE #4
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6628
Mailing Address - Country:US
Mailing Address - Phone:815-229-1899
Mailing Address - Fax:815-231-1218
Practice Address - Street 1:6090 STRATHMOOR DR
Practice Address - Street 2:SUITE #4
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6628
Practice Address - Country:US
Practice Address - Phone:815-229-1899
Practice Address - Fax:815-231-1218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0010100611OtherBCBS
IL0010100611OtherBCBS
IL938110Medicare ID - Type Unspecified