Provider Demographics
NPI:1033167770
Name:SHUPP, DAVID L (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:SHUPP
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 1:32 COLONNADE WAY
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-2309
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:500 UNIVERSITY DR
Practice Address - Street 2:SUITE 102
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2360
Practice Address - Country:US
Practice Address - Phone:800-243-1455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026767E207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026122110001Medicaid
PA221566Medicare PIN