Provider Demographics
NPI:1790733913
Name:ETWARU, GUPTA (MD)
Entity Type:Individual
Prefix:
First Name:GUPTA
Middle Name:
Last Name:ETWARU
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 1:395 CIVIC DR
Mailing Address - Street 2:G
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-1979
Mailing Address - Country:US
Mailing Address - Phone:925-817-0496
Mailing Address - Fax:925-954-6939
Practice Address - Street 1:395 CIVIC DR
Practice Address - Street 2:G
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-1979
Practice Address - Country:US
Practice Address - Phone:925-817-0496
Practice Address - Fax:925-954-6939
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83765207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G30069Medicare UPIN
00G837651Medicare ID - Type Unspecified