Provider Demographics
NPI:1962418236
Name:GUPTA, CHAMPALAL (MD)
Entity type:Individual
Prefix:DR
First Name:CHAMPALAL
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 1:5300 W VILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-4345
Mailing Address - Country:US
Mailing Address - Phone:414-438-6666
Mailing Address - Fax:414-438-6667
Practice Address - Street 1:5300 W VILLARD AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-4345
Practice Address - Country:US
Practice Address - Phone:414-438-6666
Practice Address - Fax:414-438-6667
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24166207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30414100Medicaid
WI000002860Medicare ID - Type Unspecified0014
WI30414100Medicaid