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General NPI Number Information
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NPI Number | 1972544526
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Entity Type | Individual
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Provider Name | KANCHAN GUPTA MD
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Gender | Female
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Dates
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Enumeration Date | 06/08/2006
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Last Update Date | 08/22/2022
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Provider Practice Location Address
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Address Line | 1025 S 6TH ST
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City | SPRINGFIELD
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State | IL
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Zip | 62703-2499
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Country | US
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Telephone | 217-528-7541
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 19248
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City | SPRINGFIELD
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State | IL
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Zip | 62794-9248
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Country | US
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Telephone | 217-528-7541
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 2009011501
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 036100468
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License Number State | IL
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