1619308061 NPI number — MUKESH BHAVDUTT GUPTA MD A PROFESSIONAL CORPORATION

Table of content: (NPI 1619308061)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619308061 NPI number — MUKESH BHAVDUTT GUPTA MD A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MUKESH BHAVDUTT GUPTA MD A PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619308061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 N TUSTIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92705-3807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-347-1010
Provider Business Mailing Address Fax Number:
714-647-1245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4444 MAGNOLIA AVE # C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92501-4136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-320-7799
Provider Business Practice Location Address Fax Number:
951-274-3550
Provider Enumeration Date:
12/11/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GUPTA
Authorized Official First Name:
MUKESH
Authorized Official Middle Name:
BHAVDUTT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-347-1010

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  A70036 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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