Healthcare Provider Details

I. General information

NPI: 1083790851
Provider Name (Legal Business Name): MARK KUPERWASER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE CC5
BOSTON MA
02215-5400
US

IV. Provider business mailing address

330 BROOKLINE AVE CC5
BOSTON MA
02215-5400
US

V. Phone/Fax

Practice location:
  • Phone: 617-667-3391
  • Fax:
Mailing address:
  • Phone: 617-667-3391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number58431
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: