Healthcare Provider Details

I. General information

NPI: 1114458775
Provider Name (Legal Business Name): JOSHUA GUNPAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10039 VINE ST
LAKESIDE CA
92040-3120
US

IV. Provider business mailing address

525 OLIVE ST APT 812
SAN DIEGO CA
92103-6341
US

V. Phone/Fax

Practice location:
  • Phone: 833-867-4642
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD89395
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101272132
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD049150
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number191201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: