Healthcare Provider Details

I. General information

NPI: 1699942417
Provider Name (Legal Business Name): MONA GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

417 LONGSPUR RD HIGHLAND HEIGHTS
CLEVELAND OH
44143-3718
US

V. Phone/Fax

Practice location:
  • Phone: 216-445-0624
  • Fax: 216-636-1711
Mailing address:
  • Phone: 440-461-9994
  • Fax: 440-461-9994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number35.086046
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number35.086046
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: