Provider Demographics
NPI:1902806474
Name:SHUPE, THERESA B (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:B
Last Name:SHUPE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14535 JOHN MARSHALL HIGHWAY
Mailing Address - Street 2:SUITE #105
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155
Mailing Address - Country:US
Mailing Address - Phone:703-754-0425
Mailing Address - Fax:703-754-2888
Practice Address - Street 1:14535 JOHN MARSHALL HIGHWAY
Practice Address - Street 2:SUITE #105
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155
Practice Address - Country:US
Practice Address - Phone:703-754-0425
Practice Address - Fax:703-754-2888
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058776207Q00000X
VA0101058775207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA080007114Medicare ID - Type Unspecified
VAD04707Medicare UPIN
VA5640041Medicare ID - Type Unspecified
F09586Medicare UPIN