Healthcare Provider Details

I. General information

NPI: 1861833154
Provider Name (Legal Business Name): RANJAN GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E DOUGLAS RD STE 208
MISHAWAKA IN
46545-1465
US

IV. Provider business mailing address

5215 HOLY CROSS PKWY
MISHAWAKA IN
46545-1469
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-6000
  • Fax: 574-335-0738
Mailing address:
  • Phone: 574-335-8707
  • Fax: 574-335-0741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number01099771A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: