Healthcare Provider Details

I. General information

NPI: 1790071660
Provider Name (Legal Business Name): DIVYA M GUPTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIVYA M MURTHY MD

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY
CHICAGO IL
60612-3833
US

IV. Provider business mailing address

1653 W CONGRESS PKWY
CHICAGO IL
60612-3833
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5000
  • Fax:
Mailing address:
  • Phone: 312-942-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-135575
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: