Provider Demographics
NPI:1316392814
Name:TUPIKOV, DMITRIY (DC)
Entity Type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:TUPIKOV
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11679 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-2264
Mailing Address - Country:US
Mailing Address - Phone:971-373-8257
Mailing Address - Fax:971-373-8259
Practice Address - Street 1:11679 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-2264
Practice Address - Country:US
Practice Address - Phone:971-373-8257
Practice Address - Fax:971-373-8259
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-03
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5722111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500742574Medicaid