Provider Demographics
NPI:1982058152
Name:GUPTA, NIKHIL (MD)
Entity Type:Individual
Prefix:
First Name:NIKHIL
Middle Name:
Last Name:GUPTA
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 1:17203 JASMINE ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7786
Mailing Address - Country:US
Mailing Address - Phone:760-881-3377
Mailing Address - Fax:760-881-3379
Practice Address - Street 1:17203 JASMINE ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7786
Practice Address - Country:US
Practice Address - Phone:760-881-3377
Practice Address - Fax:760-881-3350
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA151035207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANG3232267556Medicaid