Provider Demographics
NPI:1316004484
Name:KUPSAW, ROBERT ELIOT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ELIOT
Last Name:KUPSAW
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-0454
Mailing Address - Fax:239-343-1075
Practice Address - Street 1:13778 PLANTATION RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4301
Practice Address - Country:US
Practice Address - Phone:239-343-0454
Practice Address - Fax:239-343-1075
Is Sole Proprietor?:No
Enumeration Date:2007-01-01
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48214207Q00000X, 207PE0005X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1492OtherBLUE CROSS BLUE SHIELD
FL043729800Medicaid
FL221870OtherAMERIGROUP
FL297506OtherAVMED
FL297506OtherAVMED
FLP00028372Medicare PIN
FL043729800Medicaid