Healthcare Provider Details

I. General information

NPI: 1760583629
Provider Name (Legal Business Name): VANITA GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 N AIRLITE ST STE 130
ELGIN IL
60123-4991
US

IV. Provider business mailing address

87 N AIRLITE ST STE 130
ELGIN IL
60123-4991
US

V. Phone/Fax

Practice location:
  • Phone: 847-888-3661
  • Fax: 847-888-9964
Mailing address:
  • Phone: 847-888-3661
  • Fax: 847-888-9964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036114356
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number036114356
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: