Provider Demographics
NPI:1114985173
Name:CUPP, SEAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:A
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 1:11100 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1716
Mailing Address - Country:US
Mailing Address - Phone:216-844-7200
Mailing Address - Fax:
Practice Address - Street 1:24701 EUCLID AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44117-1714
Practice Address - Country:US
Practice Address - Phone:216-844-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0430814207Q00000X, 207QS0010X
OH35.124490207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200307140AMedicaid
OH0109771Medicaid
I16525Medicare UPIN
OHH372180Medicare PIN
KS200307140AMedicaid