Healthcare Provider Details

I. General information

NPI: 1255890570
Provider Name (Legal Business Name): MR. ROMERO DAVID KUPAI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2019
Last Update Date: 09/26/2023
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

IV. Provider business mailing address

2830 W POTRERO RD
THOUSAND OAKS CA
91361-5088
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-3000
  • Fax:
Mailing address:
  • Phone: 253-347-0192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberPTL320
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: