Healthcare Provider Details

I. General information

NPI: 1255369542
Provider Name (Legal Business Name): MUKESH BHAVDUTT GUPTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4049 ALMOND ST STE 102
RIVERSIDE CA
92501-3570
US

IV. Provider business mailing address

210 N TUSTIN AVE
SANTA ANA CA
92705-3807
US

V. Phone/Fax

Practice location:
  • Phone: 951-781-3945
  • Fax: 951-781-3661
Mailing address:
  • Phone: 714-347-1010
  • Fax: 714-647-1245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA70036
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: