Healthcare Provider Details

I. General information

NPI: 1467864389
Provider Name (Legal Business Name): SHIVANI GUPTA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W 95TH ST STE 306
OAK LAWN IL
60453-2659
US

IV. Provider business mailing address

1111 MEDICAL CENTER BLVD STE S750
MARRERO LA
70072-3197
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-5428
  • Fax: 708-684-2079
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036-161214
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD320466
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: