Healthcare Provider Details

I. General information

NPI: 1922089655
Provider Name (Legal Business Name): MARK J KUPERSMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 10TH AVE 10TH FL RM INN
NEW YORK NY
10019-1147
US

IV. Provider business mailing address

1000 10TH AVE 10TH FLOOR RM INN
NEW YORK NY
10019-1147
US

V. Phone/Fax

Practice location:
  • Phone: 212-636-3200
  • Fax: 212-636-3195
Mailing address:
  • Phone: 212-636-3200
  • Fax: 212-636-3195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number129274 1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number125274
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: