Healthcare Provider Details

I. General information

NPI: 1235103243
Provider Name (Legal Business Name): GEORGE STOUPAKIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SUMMIT AVE SUITE 200
HACKENSACK NJ
07601-8503
US

IV. Provider business mailing address

PO BOX 67
HACKENSACK NJ
07602-0067
US

V. Phone/Fax

Practice location:
  • Phone: 201-343-7001
  • Fax: 201-343-7232
Mailing address:
  • Phone: 201-343-7001
  • Fax: 201-343-7232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMA07271800
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0075639
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: