Healthcare Provider Details

I. General information

NPI: 1770578098
Provider Name (Legal Business Name): SIMON GABRIEL KUPCHIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

948 48TH STREET
BROOKLYN NY
11219
US

IV. Provider business mailing address

977 48TH STREET
BROOKLYN NY
11219
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-8260
  • Fax: 718-283-6147
Mailing address:
  • Phone: 718-283-7229
  • Fax: 718-635-6331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number176882
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: