Healthcare Provider Details

I. General information

NPI: 1972536241
Provider Name (Legal Business Name): MARVIN A KUPERSMIT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 REGATTA DR
JUPITER FL
33477-4077
US

IV. Provider business mailing address

333 REGATTA DR
JUPITER FL
33477-4077
US

V. Phone/Fax

Practice location:
  • Phone: 561-575-3296
  • Fax:
Mailing address:
  • Phone: 561-575-3296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MB02362300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: