Provider Demographics
NPI:1215137815
Name:GUPTA, SANDEEP (MD)
Entity type:Individual
Prefix:
First Name:SANDEEP
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 LAWRENCE EXPY
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-5173
Mailing Address - Country:US
Mailing Address - Phone:510-687-9510
Mailing Address - Fax:
Practice Address - Street 1:39500 FREMONT BLVD
Practice Address - Street 2:#100
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2101
Practice Address - Country:US
Practice Address - Phone:510-687-9510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100278207Q00000X
CA100278207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB777AMedicare PIN