Healthcare Provider Details

I. General information

NPI: 1194920595
Provider Name (Legal Business Name): SHIVANI GUPTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13652 CANTARA ST BUILDING 2
PANORAMA CITY CA
91402-5423
US

IV. Provider business mailing address

13652 CANTARA ST BUILDING 2
PANORAMA CITY CA
91402-5423
US

V. Phone/Fax

Practice location:
  • Phone: 818-375-1750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301097505
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number137240
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: