Healthcare Provider Details

I. General information

NPI: 1932267606
Provider Name (Legal Business Name): JERALD IVAN KUPPERBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 12/14/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 HOWARD HILL ROAD
FOSTER RI
02825
US

IV. Provider business mailing address

54 HOWARD HILL ROAD
FOSTER RI
02825
US

V. Phone/Fax

Practice location:
  • Phone: 401-397-4638
  • Fax: 401-397-4638
Mailing address:
  • Phone: 401-397-4638
  • Fax: 401-397-4638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD05404
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: