Provider Demographics
NPI:1306192372
Name:SHUPE, DAVID EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:EDWARD
Last Name:SHUPE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:820 PRUDENTIAL DR STE 304
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8205
Practice Address - Country:US
Practice Address - Phone:904-202-3860
Practice Address - Fax:904-202-3846
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO1515207Q00000X
SCLL 1615207Q00000X
FLOS18845207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALE869Medicare PIN