Provider Demographics
NPI:1467428045
Name:PUPP, GUY RICHARD (DPM)
Entity Type:Individual
Prefix:DR
First Name:GUY
Middle Name:RICHARD
Last Name:PUPP
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22250 PROVIDENCE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-6209
Mailing Address - Country:US
Mailing Address - Phone:248-424-8637
Mailing Address - Fax:248-424-8663
Practice Address - Street 1:22250 PROVIDENCE DR STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6209
Practice Address - Country:US
Practice Address - Phone:248-424-8637
Practice Address - Fax:248-424-8663
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGP000690213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4275305Medicaid
MI479116001OtherDME SUPPLIER #
MIOH 27788OtherBCBS
MIT34213OtherHAP PROVIDER #
OM07610Medicare ID - Type Unspecified
MIT34213OtherHAP PROVIDER #