Provider Demographics
NPI:1275709677
Name:JEFFREY B PUPP
Entity Type:Organization
Organization Name:JEFFREY B PUPP
Other - Org Name:WALLACE FOOT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:B
Authorized Official - Last Name:PUPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-285-3362
Mailing Address - Street 1:114 N NORWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:NC
Mailing Address - Zip Code:28466-2730
Mailing Address - Country:US
Mailing Address - Phone:910-285-3362
Mailing Address - Fax:910-285-6683
Practice Address - Street 1:114 N NORWOOD ST
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-2730
Practice Address - Country:US
Practice Address - Phone:910-285-3362
Practice Address - Fax:910-285-6683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC449213ES0103X
NC230213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890152PMedicaid
NC2432650AOtherMEDICARE PTAN
NCCJ7762OtherRAILROAD MEDICARE PTAN
NC0152POtherBCBS NC
NCB1114OtherMEDCOST
NCB1114OtherMEDCOST