Healthcare Provider Details

I. General information

NPI: 1518963743
Provider Name (Legal Business Name): JOHN JOSEPH KUPKO II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 PINION DR
U S A F ACADEMY CO
80840-2502
US

IV. Provider business mailing address

4144 DOUGLASS LOOP
U S A F ACADEMY CO
80840-1005
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-5680
  • Fax:
Mailing address:
  • Phone: 719-472-9571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number21551
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4910
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberM-4762
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: