Healthcare Provider Details

I. General information

NPI: 1548464332
Provider Name (Legal Business Name): AMIT GUPTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8631 W 3RD ST STE 531E
LOS ANGELES CA
90048-5901
US

IV. Provider business mailing address

8631 W 3RD ST STE 531E
LOS ANGELES CA
90048-5901
US

V. Phone/Fax

Practice location:
  • Phone: 310-734-8942
  • Fax: 310-736-6591
Mailing address:
  • Phone: 310-734-8942
  • Fax: 310-736-6591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number39557
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberC142651
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: