Provider Demographics
NPI:1174532543
Name:GUPTA, BRIJ (MD)
Entity type:Individual
Prefix:
First Name:BRIJ
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 1:2001 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2303
Mailing Address - Country:US
Mailing Address - Phone:858-720-0493
Mailing Address - Fax:858-636-2210
Practice Address - Street 1:2001 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2303
Practice Address - Country:US
Practice Address - Phone:858-720-0493
Practice Address - Fax:858-636-2210
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43950207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW22546OtherMEDICARE GROUP PTAN
CAW22546OtherMEDICARE GROUP PTAN