Provider Demographics
NPI:1487618351
Name:GUPTA, NARENDRA KUMAR (MD, FACS)
Entity type:Individual
Prefix:
First Name:NARENDRA
Middle Name:KUMAR
Last Name:GUPTA
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Gender:M
Credentials:MD, FACS
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Other - First Name:
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Mailing Address - Street 1:1054 MARTIN LUTHER KING DRIVE
Mailing Address - Street 2:SUITE 125
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801
Mailing Address - Country:US
Mailing Address - Phone:618-532-1155
Mailing Address - Fax:618-532-1117
Practice Address - Street 1:1054 MARTIN LUTHER KING DRIVE
Practice Address - Street 2:SUITE 125
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801
Practice Address - Country:US
Practice Address - Phone:618-532-1155
Practice Address - Fax:618-532-1117
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02900086OtherBLUE CROSS/BLUE SHIELD
ILD86566Medicare UPIN
IL02900086OtherBLUE CROSS/BLUE SHIELD