Healthcare Provider Details

I. General information

NPI: 1891772778
Provider Name (Legal Business Name): NISHEETH GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 RIDGE RD SUITE 5
MUNSTER IN
46321-1751
US

IV. Provider business mailing address

200 E 89TH AVE SUITE 2A
MERRILLVILLE IN
46410-7319
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-2000
  • Fax:
Mailing address:
  • Phone: 219-736-2800
  • Fax: 219-736-6680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number01042940
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: