Healthcare Provider Details

I. General information

NPI: 1285676353
Provider Name (Legal Business Name): ROBERT JOHN KUPIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 PARKWAY SOUTH SUITE 103
WATERFORD CT
06385
US

IV. Provider business mailing address

196 PARKWAY SOUTH SUITE 103
WATERFORD CT
06385
US

V. Phone/Fax

Practice location:
  • Phone: 860-443-4383
  • Fax: 860-443-3980
Mailing address:
  • Phone: 860-443-4383
  • Fax: 860-443-3980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number893
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000893
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number58266
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: