Provider Demographics
NPI:1396904249
Name:GUPTA, AVANI R (DO)
Entity type:Individual
Prefix:
First Name:AVANI
Middle Name:R
Last Name:GUPTA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 E LOS ANGELES AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3503
Mailing Address - Country:US
Mailing Address - Phone:805-306-1440
Mailing Address - Fax:805-306-1758
Practice Address - Street 1:1950 E LOS ANGELES AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3503
Practice Address - Country:US
Practice Address - Phone:805-306-1440
Practice Address - Fax:805-306-1758
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A11616207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A11616OtherOSTEOPATHIC MEDICAL BOARD LICENSE
CA20A11616OtherOSTEOPATHIC MEDICAL BOARD LICENSE