Provider Demographics
NPI:1164423109
Name:PUPKOVA, LYUDMILA STEPANOVNA (MD)
Entity Type:Individual
Prefix:DR
First Name:LYUDMILA
Middle Name:STEPANOVNA
Last Name:PUPKOVA
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 1:210 BLACKGOLD BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701
Mailing Address - Country:US
Mailing Address - Phone:606-487-0885
Mailing Address - Fax:606-487-7332
Practice Address - Street 1:210 BLACKGOLD BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701
Practice Address - Country:US
Practice Address - Phone:606-487-0885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07458500208600000X
NY228588208600000X
KY43967KY208600000X
PAMD430562208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100162020Medicaid
I01524Medicare UPIN
NJ00805Medicare ID - Type UnspecifiedCARRIER NUMBER
NJI01524Medicare UPIN