Healthcare Provider Details

I. General information

NPI: 1245650001
Provider Name (Legal Business Name): SANDEEP GUPTA MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 UNDERHILL RD
OTTAWA HILLS OH
43615-2332
US

IV. Provider business mailing address

2450 UNDERHILL RD
OTTAWA HILLS OH
43615-2332
US

V. Phone/Fax

Practice location:
  • Phone: 419-290-3672
  • Fax:
Mailing address:
  • Phone: 419-290-3672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35.122881
License Number StateOH

VIII. Authorized Official

Name: SANDEEP GUPTA
Title or Position: PSYCHIATRIST
Credential: M.D.
Phone: 419-290-3672