Healthcare Provider Details

I. General information

NPI: 1699868505
Provider Name (Legal Business Name): MANISH RAJ GUPTA, MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 ISAAC STREETS DR SUITE 136
OREGON OH
43616-3291
US

IV. Provider business mailing address

1050 ISAAC STREETS DR SUITE 136
OREGON OH
43616-3291
US

V. Phone/Fax

Practice location:
  • Phone: 419-696-5656
  • Fax:
Mailing address:
  • Phone: 419-696-5656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number35076763G
License Number StateOH

VIII. Authorized Official

Name: DR. MANISH RAJ GUPTA
Title or Position: PRESIDENT
Credential: MD
Phone: 419-696-5656