Provider Demographics
NPI:1003820150
Name:CUPP, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CUPP
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 1:105 N KEENE ST
Mailing Address - Street 2:STE 201
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8131
Mailing Address - Country:US
Mailing Address - Phone:573-499-4990
Mailing Address - Fax:573-442-2120
Practice Address - Street 1:105 N KEENE ST
Practice Address - Street 2:STE 201
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8131
Practice Address - Country:US
Practice Address - Phone:573-499-4990
Practice Address - Fax:573-442-2120
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110621208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO003012608Medicare ID - Type Unspecified
MO000012609Medicare PIN
MO000012609Medicare ID - Type Unspecified