Provider Demographics
NPI:1740289313
Name:GUPTA, VIJAY (MD)
Entity type:Individual
Prefix:
First Name:VIJAY
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 1:8840 CALUMET AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2545
Mailing Address - Country:US
Mailing Address - Phone:219-836-7246
Mailing Address - Fax:219-836-6454
Practice Address - Street 1:8840 CALUMET AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2545
Practice Address - Country:US
Practice Address - Phone:219-836-7246
Practice Address - Fax:219-836-6454
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031383A207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01031383AOtherLICENSE NUMBER
GA050056006OtherMEDICARE RAILROAD
IN100188860AMedicaid
IN000000091129OtherBLUE CROSS BLUE SHIELD
IL01031383AOtherBCBS OF ILLINOIS
IN01031383AOtherLICENSE NUMBER
IL01031383AOtherBCBS OF ILLINOIS