Provider Demographics
NPI:1518919554
Name:CANUPP, TONY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:WAYNE
Last Name:CANUPP
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 1:500 CHATHAM MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621
Mailing Address - Country:US
Mailing Address - Phone:336-835-3136
Mailing Address - Fax:336-835-6038
Practice Address - Street 1:500 CHATHAM MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621
Practice Address - Country:US
Practice Address - Phone:336-835-3136
Practice Address - Fax:336-835-6038
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18615207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7921063Medicaid
C80808Medicare UPIN
NC7921063Medicaid