Provider Demographics
NPI:1457342321
Name:KUPTEL, MIROSLAW A (MD)
Entity type:Individual
Prefix:MR
First Name:MIROSLAW
Middle Name:A
Last Name:KUPTEL
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 1:9651 IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:SCHILLER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60176-1905
Mailing Address - Country:US
Mailing Address - Phone:847-678-6474
Mailing Address - Fax:847-671-5950
Practice Address - Street 1:9651 IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:SCHILLER PARK
Practice Address - State:IL
Practice Address - Zip Code:60176-1905
Practice Address - Country:US
Practice Address - Phone:847-678-6474
Practice Address - Fax:847-671-5950
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095993207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036042993Medicaid
IL01632616OtherBLUE CROSS BLUE SCHEILD
IL203257Medicare ID - Type Unspecified
IL01632616OtherBLUE CROSS BLUE SCHEILD