Healthcare Provider Details

I. General information

NPI: 1750394367
Provider Name (Legal Business Name): PRADEEP GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 05/27/2021
Certification Date: 05/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N MORRISON RD
MUNCIE IN
47304-5568
US

IV. Provider business mailing address

3401 N MORRISON RD
MUNCIE IN
47304-5568
US

V. Phone/Fax

Practice location:
  • Phone: 765-254-5602
  • Fax:
Mailing address:
  • Phone: 765-254-5602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number0101231407
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: