Healthcare Provider Details

I. General information

NPI: 1124005863
Provider Name (Legal Business Name): MANISH R GUPTA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 02/06/2015
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: 419-844-8784
Mailing address:
  • Phone: 419-696-5656
  • Fax: 419-844-8784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number35-07-6763-G
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: