Healthcare Provider Details

I. General information

NPI: 1700145182
Provider Name (Legal Business Name): JACOB EDWIN KUPERSTOCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2012
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 UNIVERSITY DR STE 300
FAIRFAX VA
22030
US

IV. Provider business mailing address

3801 UNIVERSITY DR STE 300
FAIRFAX VA
22030-2503
US

V. Phone/Fax

Practice location:
  • Phone: 703-383-8130
  • Fax: 703-383-7355
Mailing address:
  • Phone: 703-383-8130
  • Fax: 703-383-7355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number255486
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number0101266254
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: