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General NPI Number Information
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NPI Number | 1396063046
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Entity Type | Organization
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Legal Business Name | GAUTAM GUPTA MD LLC
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Dates
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Enumeration Date | 05/05/2010
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Last Update Date | 05/05/2010
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Provider Practice Location Address
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Address Line | 6090 STRATHMOOR DR
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City | ROCKFORD
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State | IL
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Zip | 61107-6628
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Country | US
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Telephone | 815-229-1899
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Fax |
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Provider Business Mailing Address
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Address Line | 4525 FOREST VIEW AVE
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City | ROCKFORD
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State | IL
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Zip | 61108-6406
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Country | US
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Telephone | 815-965-8505
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Fax | 815-965-8440
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Authorized Official
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Title or Position | OWNER
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Name | GAUTAM GUPTA
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Credential | MD
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Telephone | 815-229-1899
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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