Healthcare Provider Details

I. General information

NPI: 1972336154
Provider Name (Legal Business Name): STEPHEN EZRA PUPKIN MS, CGC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4494 PALMER ROAD N BUILDING 19, 3RD FLOOR
BETHESDA MD
20889
US

IV. Provider business mailing address

4494 PALMER ROAD N BUILDING 19, 3RD FLOOR
BETHESDA MD
20889-0001
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-4283
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberG0000149
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: