Healthcare Provider Details

I. General information

NPI: 1063510857
Provider Name (Legal Business Name): JYOTI GUPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40910 FREMONT BLVD
FREMONT CA
94538
US

IV. Provider business mailing address

179 EMORY CMN
FREMONT CA
94539-4796
US

V. Phone/Fax

Practice location:
  • Phone: 510-252-6862
  • Fax:
Mailing address:
  • Phone: 212-518-8676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number155105
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number229248
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: