Healthcare Provider Details

I. General information

NPI: 1174522726
Provider Name (Legal Business Name): JEFFREY KRUPEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21432 43RD AVE
BAYSIDE NY
11361-2956
US

IV. Provider business mailing address

21432 43RD AVE
BAYSIDE NY
11361-2956
US

V. Phone/Fax

Practice location:
  • Phone: 718-224-7200
  • Fax: 718-224-7582
Mailing address:
  • Phone: 718-224-7200
  • Fax: 718-224-7582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number155153
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: