Provider Demographics
NPI:1356637185
Name:GUPTA, SAURABH (PHD)
Entity Type:Individual
Prefix:DR
First Name:SAURABH
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:SYRUS
Other - Middle Name:
Other - Last Name:GUPTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:3990 OLD TOWN AVE
Mailing Address - Street 2:STE. A-208
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-2930
Mailing Address - Country:US
Mailing Address - Phone:619-537-9345
Mailing Address - Fax:619-269-9245
Practice Address - Street 1:3990 OLD TOWN AVE
Practice Address - Street 2:STE. A-208
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2930
Practice Address - Country:US
Practice Address - Phone:619-537-9345
Practice Address - Fax:619-269-9245
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24218103G00000X, 103T00000X, 103TC0700X, 103TC1900X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
12258947OtherCAQH