Healthcare Provider Details

I. General information

NPI: 1538962394
Provider Name (Legal Business Name): SHASHANK GUPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2025
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 W WARREN BLVD APT 205
CHICAGO IL
60612-2618
US

IV. Provider business mailing address

1609 W WARREN BLVD APT 205
CHICAGO IL
60612-2618
US

V. Phone/Fax

Practice location:
  • Phone: 415-500-5644
  • Fax:
Mailing address:
  • Phone: 415-500-5644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125.085411
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: