Healthcare Provider Details

I. General information

NPI: 1649388893
Provider Name (Legal Business Name): KENNETH M KUPKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WATERMAN WAY
TAVARES FL
32778-5266
US

IV. Provider business mailing address

PO BOX 3130
OCALA FL
34478-3130
US

V. Phone/Fax

Practice location:
  • Phone: 352-253-3333
  • Fax: 352-589-3487
Mailing address:
  • Phone: 352-867-8311
  • Fax: 352-867-1053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME45826
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: