Healthcare Provider Details

I. General information

NPI: 1952554917
Provider Name (Legal Business Name): DEEPTI GUPTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 10/23/2021
Certification Date: 10/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227 E LOS ANGELES AVE
SIMI VALLEY CA
93065-2871
US

IV. Provider business mailing address

800 S VICTORIA AVE # L4640
VENTURA CA
93009-0003
US

V. Phone/Fax

Practice location:
  • Phone: 805-582-4000
  • Fax:
Mailing address:
  • Phone: 805-677-5146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA110895
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: