Provider Demographics
NPI:1609077197
Name:GUPTA, MANJUSHA (MD)
Entity Type:Individual
Prefix:DR
First Name:MANJUSHA
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 TOWNE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1573
Practice Address - Street 1:1866 N ORANGE GROVE AVE
Practice Address - Street 2:SUITE # 102
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3031
Practice Address - Country:US
Practice Address - Phone:909-865-0676
Practice Address - Fax:909-865-8483
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102011207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1609077197Medicaid
CABN956GMedicare PIN
CA1609077197Medicaid