Provider Demographics
NPI:1376781575
Name:GUPTA, VIPUL (MBBS)
Entity Type:Individual
Prefix:
First Name:VIPUL
Middle Name:
Last Name:GUPTA
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 W EL CAMINO REAL FL 2
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-6203
Mailing Address - Country:US
Mailing Address - Phone:925-776-7725
Mailing Address - Fax:925-757-0849
Practice Address - Street 1:4053 LONE TREE WAY STE 200
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531
Practice Address - Country:US
Practice Address - Phone:925-776-7725
Practice Address - Fax:925-757-0849
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA119408207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA119408OtherSTATE MEDICAL LICENSE
CAFG3303954OtherFEDERAL DEA LICENSE