MEDICARE: AVANI R GUPTA DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	20A11616	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20A11616	OTHER	CA	OSTEOPATHIC MEDICAL BOARD LICENSE

General Provider Information

NPI Number	:	1396904249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AVANI R GUPTA DO

Provider Business Mailing Address
First Line	:	1950 E LOS ANGELES AVE
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-3503
Country	:	US
Telephone Number	:	805-306-1440
Fax Number	:	805-306-1758

Provider Business Practice Location Address
First Line	:	1950 E LOS ANGELES AVE
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-3503
Country	:	US
Telephone Number	:	805-306-1440
Fax Number	:	805-306-1758

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2008
Last Update Date	:	02/24/2014

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Directions to “ AVANI R GUPTA DO” Practice Location

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