Healthcare Provider Details

I. General information

NPI: 1679542880
Provider Name (Legal Business Name): AJAY GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE S-51/NEUROLOGY, CLEVELAND CLINIC FOUNDATION
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

35700 SPICEBUSH LN
SOLON OH
44139-5061
US

V. Phone/Fax

Practice location:
  • Phone: 216-445-7728
  • Fax: 216-445-6813
Mailing address:
  • Phone: 440-394-8193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number67037
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number67037
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number35.074602
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number35.074602
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: