Provider Demographics
NPI:1891765574
Name:GUPTA, VINOD KUMAR (MD)
Entity type:Individual
Prefix:DR
First Name:VINOD
Middle Name:KUMAR
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 1:2190 LYNN RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-1980
Mailing Address - Country:US
Mailing Address - Phone:805-495-8050
Mailing Address - Fax:805-495-2160
Practice Address - Street 1:2876 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1550
Practice Address - Country:US
Practice Address - Phone:805-527-6616
Practice Address - Fax:805-526-7001
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA032271174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A322710Medicaid
CAWA32271FMedicare PIN
CAA87671Medicare UPIN