Healthcare Provider Details

I. General information

NPI: 1134360175
Provider Name (Legal Business Name): ERIN JEANNINE CUPOLO D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5205 STILESBORO RD NW STE 205
KENNESAW GA
30152-7765
US

IV. Provider business mailing address

5205 STILESBORO RD NW SUITE 205
KENNESAW GA
30152-7744
US

V. Phone/Fax

Practice location:
  • Phone: 678-310-0540
  • Fax: 678-310-0538
Mailing address:
  • Phone: 678-310-0540
  • Fax: 678-310-0538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD001163
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: