Provider Demographics
NPI:1861519563
Name:GUPTA, PAVAN KUMAR (MD)
Entity type:Individual
Prefix:DR
First Name:PAVAN
Middle Name:KUMAR
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:THREE SAINT ELIZABETH BLVD STE 2800
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1282
Mailing Address - Country:US
Mailing Address - Phone:618-233-6044
Mailing Address - Fax:833-973-4218
Practice Address - Street 1:THREE SAINT ELIZABETH BLVD STE 2800
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1282
Practice Address - Country:US
Practice Address - Phone:618-233-6044
Practice Address - Fax:833-973-4218
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083827208M00000X, 390200000X, 207R00000X
RIMD13290207R00000X
IL036130576207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036130576Medicaid
IL036130576Medicaid