Healthcare Provider Details

I. General information

NPI: 1023221835
Provider Name (Legal Business Name): MICHELLE N KUPERMINC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708
US

IV. Provider business mailing address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-9007
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-5652
  • Fax: 757-953-7134
Mailing address:
  • Phone: 757-953-5652
  • Fax: 757-953-7134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116017586
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number0101243918
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: