Healthcare Provider Details

I. General information

NPI: 1144205881
Provider Name (Legal Business Name): PATRICK A KUPELIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 09/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLZ B265
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-0128
  • Fax: 407-425-5203
Mailing address:
  • Phone: 310-825-0128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberC54049
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: