Provider Demographics
NPI:1730343344
Name:GUPTA, CARMEN VALERIA (MD)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:VALERIA
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:VALERIA
Other - Last Name:PITTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10243 GENETIC CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-6310
Mailing Address - Country:US
Mailing Address - Phone:858-499-2704
Mailing Address - Fax:
Practice Address - Street 1:10243 GENETIC CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-6310
Practice Address - Country:US
Practice Address - Phone:858-499-2704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-12
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4173207Q00000X
CAA124838207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX308215801Medicaid
TXB165126Medicare PIN