Healthcare Provider Details

I. General information

NPI: 1811956980
Provider Name (Legal Business Name): MICAL J KUPKE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2006
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 NEALY BLVD
LANGLEY AFB VA
23665-2023
US

IV. Provider business mailing address

114 PELICAN PL
YORKTOWN VA
23692-2983
US

V. Phone/Fax

Practice location:
  • Phone: 757-764-3260
  • Fax:
Mailing address:
  • Phone: 757-225-8001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number010106772
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101056772
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number0101056772
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: