Healthcare Provider Details

I. General information

NPI: 1306835350
Provider Name (Legal Business Name): ISAIAS R CUPINO JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ROSERA ST
LENA WI
54139-9169
US

IV. Provider business mailing address

200 S ROSERA ST
LENA WI
54139-9169
US

V. Phone/Fax

Practice location:
  • Phone: 920-829-6400
  • Fax: 920-829-6403
Mailing address:
  • Phone: 920-829-6400
  • Fax: 920-829-6403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37208020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: