Provider Demographics
NPI:1316038490
Name:SCUPHAM, RICHARD KENT (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:KENT
Last Name:SCUPHAM
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 1:1212 PLEASANT
Mailing Address - Street 2:#LL3
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1414
Mailing Address - Country:US
Mailing Address - Phone:515-241-8866
Mailing Address - Fax:515-241-8855
Practice Address - Street 1:1212 PLEASANT
Practice Address - Street 2:#LL3
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1414
Practice Address - Country:US
Practice Address - Phone:515-241-8866
Practice Address - Fax:515-241-8855
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24041207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0147835Medicaid
IA0147835Medicaid
E47267Medicare UPIN