Provider Demographics
NPI:1306259668
Name:GUPTA, ANIRUDH (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:ANIRUDH
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 W BROADWAY APT 743
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-5081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 N ASHWOOD AVE
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1810
Practice Address - Country:US
Practice Address - Phone:805-658-5800
Practice Address - Fax:805-642-1928
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1715242084N0400X
TXBP10051031390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program