Healthcare Provider Details

I. General information

NPI: 1114420304
Provider Name (Legal Business Name): KHUSHBOO GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39000 BOB HOPE DR
RANCHO MIRAGE CA
92270-3221
US

IV. Provider business mailing address

39000 BOB HOPE DR
RANCHO MIRAGE CA
92270-3221
US

V. Phone/Fax

Practice location:
  • Phone: 760-674-3850
  • Fax:
Mailing address:
  • Phone: 760-674-3850
  • Fax: 760-674-3852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number036.150928
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number312065-01
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberE-15687
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberA188189
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: