Provider Demographics
NPI:1699802942
Name:PUPPO, LOUIS (MD)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:PUPPO
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 1:10692 CRESTWOOD DR STE B
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-4410
Mailing Address - Country:US
Mailing Address - Phone:703-754-1524
Mailing Address - Fax:703-754-7661
Practice Address - Street 1:10692 CRESTWOOD DR STE B
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109
Practice Address - Country:US
Practice Address - Phone:703-754-1524
Practice Address - Fax:703-754-7661
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048370208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1699802942Medicaid