Healthcare Provider Details

I. General information

NPI: 1477506673
Provider Name (Legal Business Name): HENRY G. CUPSTID MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1690 SKYLYN DR STE 210
SPARTANBURG SC
29307-1075
US

IV. Provider business mailing address

PO BOX 743070
ATLANTA GA
30374-3070
US

V. Phone/Fax

Practice location:
  • Phone: 864-253-8170
  • Fax: 864-585-7787
Mailing address:
  • Phone: 864-560-4304
  • Fax: 864-560-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11844
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: