Provider Demographics
NPI:1174578843
Name:GUPTA, MOHINA (MD)
Entity type:Individual
Prefix:DR
First Name:MOHINA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MOHINA
Other - Middle Name:
Other - Last Name:GUPTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1870 W WINCHESTER RD STE 248
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5360
Mailing Address - Country:US
Mailing Address - Phone:847-281-8902
Mailing Address - Fax:847-281-8906
Practice Address - Street 1:1870 W WINCHESTER RD STE 248
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5360
Practice Address - Country:US
Practice Address - Phone:847-281-8902
Practice Address - Fax:847-281-8906
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103173207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL336063864OtherCONTROLLED SUBSTANCE
IL036103173OtherPROFESSIONAL LICENSE
IL036103173Medicaid
ILBG6973324OtherDEA
ILBG6973324OtherDEA
IL036103173Medicaid