Provider Demographics
NPI:1053305458
Name:GUPTA, JIWAN P (MD)
Entity Type:Individual
Prefix:DR
First Name:JIWAN
Middle Name:P
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 1:33 MONTGOMERY
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-5115
Mailing Address - Country:US
Mailing Address - Phone:949-648-3878
Mailing Address - Fax:949-486-4417
Practice Address - Street 1:14795 JEFFREY RD STE 204
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-0417
Practice Address - Country:US
Practice Address - Phone:949-486-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37323261QX0100X, 207L00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA37323Medicare ID - Type Unspecified
CAA28353Medicare UPIN