Healthcare Provider Details

I. General information

NPI: 1851836084
Provider Name (Legal Business Name): ANKUR GUPTA MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/25/2016
Last Update Date: 12/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E 28TH ST SUITE #314
LONG BEACH CA
90806-2759
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:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA104116
License Number StateCA

VIII. Authorized Official

Name: ANKUR GUPTA
Title or Position: PRESIDENT
Credential:
Phone: 650-224-8977