Healthcare Provider Details

I. General information

NPI: 1639599855
Provider Name (Legal Business Name): THOMAS CRAIG KUPIEC II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2014
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4509 INTEGRIS PKWY STE 200
EDMOND OK
73034
US

IV. Provider business mailing address

5300 N INDEPENDENCE AVE STE 280
OKLAHOMA CITY OK
73112-5555
US

V. Phone/Fax

Practice location:
  • Phone: 405-657-3950
  • Fax: 405-471-0040
Mailing address:
  • Phone: 405-657-3950
  • Fax: 405-471-0040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number30738
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30738
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: