Provider Demographics
NPI:1740358308
Name:GUPTA, PURNENDU (MD)
Entity type:Individual
Prefix:
First Name:PURNENDU
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 1:2211 NORTH OAK PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60707-3329
Mailing Address - Country:US
Mailing Address - Phone:773-385-5497
Mailing Address - Fax:773-385-5488
Practice Address - Street 1:2211 NORTH OAK PARK AVENUE
Practice Address - Street 2:SUITE 3A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60707-3329
Practice Address - Country:US
Practice Address - Phone:773-385-5497
Practice Address - Fax:773-385-5488
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36086266207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086266Medicaid
G20388Medicare UPIN