Provider Demographics
NPI:1073629549
Name:GUPTA, ANUJ (MD)
Entity Type:Individual
Prefix:
First Name:ANUJ
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 1:2023 W VISTA WAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6030
Mailing Address - Country:US
Mailing Address - Phone:619-330-8771
Mailing Address - Fax:619-330-8772
Practice Address - Street 1:2023 W VISTA WAY
Practice Address - Street 2:SUITE D
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6030
Practice Address - Country:US
Practice Address - Phone:619-330-8771
Practice Address - Fax:619-330-8772
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85939207LP2900X, 207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1409987Medicaid
TX190104301Medicaid
LA4K885F699Medicare PIN