Healthcare Provider Details

I. General information

NPI: 1760664064
Provider Name (Legal Business Name): JOEL KUPERSMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 11/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 VERMONT AVE NW
WASHINGTON DC
20420-0001
US

IV. Provider business mailing address

810 VERMONT AVE NW
WASHINGTON DC
20420-0001
US

V. Phone/Fax

Practice location:
  • Phone: 202-254-0183
  • Fax: 202-254-0460
Mailing address:
  • Phone: 202-254-0183
  • Fax: 202-254-0460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number095920 -- 1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: