Provider Demographics
NPI:1285745158
Name:SHUPUT, STEPHEN R (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:SHUPUT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43314 BANDA TER
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-5660
Mailing Address - Country:US
Mailing Address - Phone:800-991-6704
Mailing Address - Fax:408-444-8845
Practice Address - Street 1:43314 BANDA TER
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-5660
Practice Address - Country:US
Practice Address - Phone:800-991-6704
Practice Address - Fax:408-444-8845
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27419207L00000X
UT82-169038-1205207L00000X
CAG52161207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8492795Medicaid
UT870545614SH1OtherEDUCATORS MUTUAL
UTPRA05848OtherMOLINA
UT107005104101OtherIHC
UT2090168OtherUNITED HEALTHCARE
UT8597445OtherWORKERS COMP
UTQM0000075886OtherALTIUS
ID003075300Medicaid
OR006393Medicaid
UT37817OtherPEHP
WY108049100Medicaid
ORP00611182OtherRR MEDICARE
NV100501223Medicaid
UT1502954OtherUMWA
UT36407OtherDESERET MUTUAL
UT53268OtherHEALTHY U
AZ820838Medicaid
WA8492795Medicaid
UT36407OtherDESERET MUTUAL
WY108049100Medicaid
AZ820838Medicaid