Healthcare Provider Details

I. General information

NPI: 1285745158
Provider Name (Legal Business Name): STEPHEN R SHUPUT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43314 BANDA TER
FREMONT CA
94539-5660
US

IV. Provider business mailing address

43314 BANDA TER
FREMONT CA
94539-5660
US

V. Phone/Fax

Practice location:
  • Phone: 800-991-6704
  • Fax: 408-444-8845
Mailing address:
  • Phone: 800-991-6704
  • Fax: 408-444-8845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD27419
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number82-169038-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG52161
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: