Healthcare Provider Details

I. General information

NPI: 1124095823
Provider Name (Legal Business Name): MADHUKAR GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 10/24/2020
Certification Date: 10/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11140 MONTGOMERY RD
CINCINNATI OH
45249-2309
US

IV. Provider business mailing address

4380 MALSBARY RD SUITE 200
CINCINNATI OH
45242-5644
US

V. Phone/Fax

Practice location:
  • Phone: 513-792-7800
  • Fax: 513-792-7807
Mailing address:
  • Phone: 513-366-4488
  • Fax: 513-366-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35083146
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number35083146
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: