Provider Demographics
NPI:1124095823
Name:GUPTA, MADHUKAR (MD)
Entity type:Individual
Prefix:
First Name:MADHUKAR
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4380 MALSBARY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5644
Mailing Address - Country:US
Mailing Address - Phone:513-366-4488
Mailing Address - Fax:513-366-4480
Practice Address - Street 1:11140 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-2309
Practice Address - Country:US
Practice Address - Phone:513-792-7800
Practice Address - Fax:513-792-7807
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35083146207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000310785OtherANTHEM
283830OtherAMERIGROUP
OH2435805Medicaid
KY64088099Medicaid
1519679400OtherWORKMANS COMP
2503778OtherUNITED
IN200503740Medicaid
283830OtherAMERIGROUP
IN200503740Medicaid
OH4115675Medicare PIN