Healthcare Provider Details

I. General information

NPI: 1083854582
Provider Name (Legal Business Name): ANKUR GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2009
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E 28TH ST STE 314
LONG BEACH CA
90806-2702
US

IV. Provider business mailing address

PO BOX 3672
LOS ALTOS CA
94024-0672
US

V. Phone/Fax

Practice location:
  • Phone: 562-981-9308
  • Fax: 562-981-9318
Mailing address:
  • Phone: 650-224-8977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA104116
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA104116
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: