Provider Demographics
NPI:1194070334
Name:KUPER III, KENNETH EARL
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:EARL
Last Name:KUPER III
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:EARL
Other - Last Name:KUPER
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:P.O. BOX 173891
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-5000
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100877390200000X
CODR.0055209207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO18808278Medicaid
MI4301100877OtherMEDICAL LICENSE
CO18808278Medicaid