Provider Demographics
NPI:1376760900
Name:GUPTA, MAMATHA M (MD)
Entity Type:Individual
Prefix:DR
First Name:MAMATHA
Middle Name:M
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MAMATHA
Other - Middle Name:MAKAM
Other - Last Name:NAGABHUSHANAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10535 HOSPITAL WAY
Mailing Address - Street 2:
Mailing Address - City:MATHER
Mailing Address - State:CA
Mailing Address - Zip Code:95655-4200
Mailing Address - Country:US
Mailing Address - Phone:916-843-7000
Mailing Address - Fax:
Practice Address - Street 1:10535 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:MATHER
Practice Address - State:CA
Practice Address - Zip Code:95655-4200
Practice Address - Country:US
Practice Address - Phone:916-843-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36665207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ222566Medicaid
AZ222566Medicaid