Healthcare Provider Details

I. General information

NPI: 1013198761
Provider Name (Legal Business Name): DIPTI GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2007
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST STE 800
CHICAGO IL
60611-2978
US

IV. Provider business mailing address

676 N SAINT CLAIR ST STE 800
CHICAGO IL
60611-2978
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-5753
  • Fax: 312-695-5465
Mailing address:
  • Phone: 312-695-5753
  • Fax: 312-695-5465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036130834
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: