Healthcare Provider Details

I. General information

NPI: 1316004484
Provider Name (Legal Business Name): ROBERT ELIOT KUPSAW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2007
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13778 PLANTATION RD
FORT MYERS FL
33912-4301
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-0454
  • Fax: 239-343-1075
Mailing address:
  • Phone: 239-343-0454
  • Fax: 239-343-1075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME48214
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License NumberME48214
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME48214
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: