Provider Demographics
NPI:1518456581
Name:PUPOVIC, EMILY GRACE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:GRACE
Last Name:PUPOVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WIXON POND RD
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-3529
Mailing Address - Country:US
Mailing Address - Phone:347-361-2353
Mailing Address - Fax:
Practice Address - Street 1:107 WIXON POND RD
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-3529
Practice Address - Country:US
Practice Address - Phone:347-361-2353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-05
Last Update Date:2018-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist