Healthcare Provider Details

I. General information

NPI: 1013959287
Provider Name (Legal Business Name): RONALD B KUPPERSMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 BIRMINGHAM DR
COLLEGE STATION TX
77845-4063
US

IV. Provider business mailing address

PO BOX 10194
COLLEGE STATION TX
77842-0194
US

V. Phone/Fax

Practice location:
  • Phone: 979-693-6000
  • Fax: 979-693-1900
Mailing address:
  • Phone: 979-693-6000
  • Fax: 979-693-1900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberL5799
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberL5799
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberL5799
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: