Healthcare Provider Details

I. General information

NPI: 1093797318
Provider Name (Legal Business Name): MANJU GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RIVER VALLEY BLVD
NEW RICHMOND OH
45157-8566
US

IV. Provider business mailing address

424 WARDS CORNER RD STE 200
LOVELAND OH
45140-6966
US

V. Phone/Fax

Practice location:
  • Phone: 513-553-3114
  • Fax: 513-553-1032
Mailing address:
  • Phone: 513-707-4041
  • Fax: 513-576-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number35044556
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: