Healthcare Provider Details

I. General information

NPI: 1942525811
Provider Name (Legal Business Name): PRAMOD RAMKJANAK GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2010
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W OKLAHOMA AVE
MILWAUKEE WI
53215-4330
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-649-6000
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number01091000A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036-164338
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number56867
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number56867
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: