Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Y00000X | Otolaryngologist (ENT Doctor) | 255486 | MA |
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 0101266254 | VA |
NPI | 1700145182 |
---|---|
Provider Name | Jacob Edwin Kuperstock |
First Address | Fairfax, VA 22030-2503 |
Second Address | Fairfax, VA 22030 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/05/2012 |
Last Update Date | 24/07/2019 |