Healthcare Provider Details

I. General information

NPI: 1013069780
Provider Name (Legal Business Name): MARK P KUPER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6251 OAKMONT BLVD
FORT WORTH TX
76132-3119
US

IV. Provider business mailing address

6251 OAKMONT BLVD
FORT WORTH TX
76132-3119
US

V. Phone/Fax

Practice location:
  • Phone: 817-735-9397
  • Fax: 817-735-8340
Mailing address:
  • Phone: 817-735-9397
  • Fax: 817-735-8340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberL7789
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberL7789
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: