Healthcare Provider Details

I. General information

NPI: 1306388087
Provider Name (Legal Business Name): GOPIKA GANGUPANTULA, MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2016
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 COFFEE RD STE D
MODESTO CA
95355-4229
US

IV. Provider business mailing address

1213 COFFEE RD STE D
MODESTO CA
95355-4229
US

V. Phone/Fax

Practice location:
  • Phone: 209-497-4677
  • Fax: 209-300-7172
Mailing address:
  • Phone: 209-497-4677
  • Fax: 209-300-7172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QD0401X
TaxonomyDiabetology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA81025
License Number StateCA

VIII. Authorized Official

Name: MR. SACHIN GANGUPANTULA
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 209-497-4677