Healthcare Provider Details

I. General information

NPI: 1033630785
Provider Name (Legal Business Name): VENKATA S GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE ML 7009
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3333 BURNET AVE ML 7009
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 312-404-8849
  • Fax:
Mailing address:
  • Phone: 312-404-8849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberIMLC.MD.70130552
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.150240
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-172098
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: