Provider Demographics
NPI:1699754838
Name:KUPPERSMITH, JEFFREY DAVID (DC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DAVID
Last Name:KUPPERSMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 N GILBERT RD
Mailing Address - Street 2:SUITE 309
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-4502
Mailing Address - Country:US
Mailing Address - Phone:480-926-1111
Mailing Address - Fax:480-926-2958
Practice Address - Street 1:610 N GILBERT RD
Practice Address - Street 2:SUITE 309
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-4502
Practice Address - Country:US
Practice Address - Phone:480-926-1111
Practice Address - Fax:480-926-2958
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7280111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ619494Medicaid
AZ619494Medicaid