Provider Demographics
NPI:1720055379
Name:GUPTA, SANDEEP (MD)
Entity Type:Individual
Prefix:
First Name:SANDEEP
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 MCKNIGHT DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-4890
Mailing Address - Country:US
Mailing Address - Phone:513-217-6400
Mailing Address - Fax:513-217-6037
Practice Address - Street 1:103 MCKNIGHT DR
Practice Address - Street 2:SUITE A
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-4890
Practice Address - Country:US
Practice Address - Phone:513-217-6400
Practice Address - Fax:513-217-6037
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072259207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH283835OtherAMERIGROUP
OH000000522400OtherANTHEM BCBS
OH2027989Medicaid
OHGU4106315OtherMEDICARE (OHIO) INDIVIDUAL NPI
OH208679830028OtherCARESOURCE
OH2027989OtherMOLINA HEALTHCARE
OH2027989Medicaid