Healthcare Provider Details

I. General information

NPI: 1013938257
Provider Name (Legal Business Name): ANUJA GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N WALL ST SUITE 100
KANKAKEE IL
60901-2942
US

IV. Provider business mailing address

1905 W COURT ST
KANKAKEE IL
60901-3163
US

V. Phone/Fax

Practice location:
  • Phone: 815-933-2557
  • Fax:
Mailing address:
  • Phone: 815-935-7256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number2004-0758
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: