Provider Demographics
NPI:1558369645
Name:PUPA, SANDRA H (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:H
Last Name:PUPA
Suffix:
Gender:F
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:PO BOX 908
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-0908
Mailing Address - Country:US
Mailing Address - Phone:601-703-4282
Mailing Address - Fax:601-703-4597
Practice Address - Street 1:1730A 14TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4140
Practice Address - Country:US
Practice Address - Phone:601-703-4395
Practice Address - Fax:601-703-4394
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2013-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS137532085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009601090Medicaid
300074586OtherRAILROAD MEDICARE
730-74365OtherBLUE CROSS OF AL
MS00115892Medicaid
AL009601090Medicaid
300000401Medicare ID - Type Unspecified