Healthcare Provider Details

I. General information

NPI: 1477999803
Provider Name (Legal Business Name): MATTHEW CHARLES KRUPPENBACHER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 RIDGEWAY AVE STE 440
ROCHESTER NY
14626
US

IV. Provider business mailing address

2655 RIDGEWAY AVE STE 440
ROCHESTER NY
14626-4296
US

V. Phone/Fax

Practice location:
  • Phone: 585-723-7705
  • Fax: 585-723-7788
Mailing address:
  • Phone: 585-723-7705
  • Fax: 585-723-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number286214
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number286214
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: