Provider Demographics
NPI:1275641318
Name:KUPPERBERG, LAURANCE (MD)
Entity Type:Individual
Prefix:
First Name:LAURANCE
Middle Name:
Last Name:KUPPERBERG
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 1:102 S ATWOOD RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-3608
Mailing Address - Country:US
Mailing Address - Phone:410-420-9980
Mailing Address - Fax:410-420-9975
Practice Address - Street 1:102 S ATWOOD RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-3608
Practice Address - Country:US
Practice Address - Phone:410-420-9980
Practice Address - Fax:410-420-9975
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0016606174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB70569Medicare UPIN
MD806M400FMedicare PIN