Healthcare Provider Details

I. General information

NPI: 1558320176
Provider Name (Legal Business Name): SURESH CHANDER GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 W BROAD ST
COLUMBUS OH
43228-1607
US

IV. Provider business mailing address

5100 W BROAD ST
COLUMBUS OH
43228-1607
US

V. Phone/Fax

Practice location:
  • Phone: 314-428-8335
  • Fax: 314-426-2684
Mailing address:
  • Phone: 314-428-8335
  • Fax: 314-426-2684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35-04-4862-G
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: