Provider Demographics
NPI:1326010091
Name:GUPTA, BHUSHAN CHANDER (MD)
Entity Type:Individual
Prefix:
First Name:BHUSHAN
Middle Name:CHANDER
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 1:290 BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3915
Mailing Address - Country:US
Mailing Address - Phone:650-343-4597
Mailing Address - Fax:860-229-9942
Practice Address - Street 1:290 BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3915
Practice Address - Country:US
Practice Address - Phone:650-343-4597
Practice Address - Fax:650-343-3402
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34619207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1195148Medicaid
B78549Medicare UPIN