Healthcare Provider Details

I. General information

NPI: 1790170561
Provider Name (Legal Business Name): SHIVANI RANI GUPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W BOWERY ST FL 6
AKRON OH
44308-1069
US

IV. Provider business mailing address

11819 DORENA CIR NW
UNIONTOWN OH
44685-6674
US

V. Phone/Fax

Practice location:
  • Phone: 330-543-7397
  • Fax:
Mailing address:
  • Phone: 843-371-4659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number34.012646
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: