Provider Demographics
NPI:1285674010
Name:KUPONIYI, PETER O (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:O
Last Name:KUPONIYI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:OLATUNJI
Other - Middle Name:
Other - Last Name:KUPONIYI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2626 TILTON RD
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-1829
Mailing Address - Country:US
Mailing Address - Phone:609-568-5000
Mailing Address - Fax:609-568-5010
Practice Address - Street 1:2626 TILTON RD
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-1829
Practice Address - Country:US
Practice Address - Phone:609-568-5000
Practice Address - Fax:609-568-5010
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA059488207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5535603Medicaid
NJF57908Medicare UPIN
NJ5535603Medicaid