MEDICARE: DR. MOHINA GUPTA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	036103173	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	336063864	OTHER	IL	CONTROLLED SUBSTANCE
2	036103173	OTHER	IL	PROFESSIONAL LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174578843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MOHINA GUPTA MD

Provider Business Mailing Address
First Line	:	1870 W WINCHESTER RD STE 248
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-5360
Country	:	US
Telephone Number	:	847-281-8902
Fax Number	:	847-281-8906

Provider Business Practice Location Address
First Line	:	1870 W WINCHESTER RD STE 248
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-5360
Country	:	US
Telephone Number	:	847-281-8902
Fax Number	:	847-281-8906

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	03/07/2023

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