Healthcare Provider Details

I. General information

NPI: 1093911083
Provider Name (Legal Business Name): SARULATHA M KUPPA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14040 NORTHDALE BLVD
ROGERS MN
55374
US

IV. Provider business mailing address

1435 HAMPSHIRE AVE S #212
ST LOUIS PARK MN
55426-2167
US

V. Phone/Fax

Practice location:
  • Phone: 763-488-4100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number49173
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: