MEDICARE: CHANDAN GUPTA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	72286	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437150927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANDAN GUPTA MD

Provider Business Mailing Address
First Line	:	3170 KETTERING BLVD BLDG B
Second Line	:
City	:	MORAINE
State	:	OH
Zip	:	45439-1924
Country	:	US
Telephone Number	:	379-913-1889
Fax Number	:	372-239-8119

Provider Business Practice Location Address
First Line	:	20 OVERBROOK DR
Second Line	:	SUITE C
City	:	MONROE
State	:	OH
Zip	:	45050-3101
Country	:	US
Telephone Number	:	513-539-7356
Fax Number	:	513-539-7782

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	03/23/2022

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Directions to “ CHANDAN GUPTA MD” Practice Location

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