Provider Demographics
NPI:1306378104
Name:TUPPER, KRISTOFER NATHANIEL (DO)
Entity Type:Individual
Prefix:
First Name:KRISTOFER
Middle Name:NATHANIEL
Last Name:TUPPER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-5508
Mailing Address - Country:US
Mailing Address - Phone:203-337-2600
Mailing Address - Fax:203-337-2611
Practice Address - Street 1:305 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-5508
Practice Address - Country:US
Practice Address - Phone:203-337-2600
Practice Address - Fax:203-337-2611
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT69436207Q00000X, 207QS0010X
RILP04070207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty