Provider Demographics
NPI:1629186481
Name:SHUPACK, IAN S (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:S
Last Name:SHUPACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7571 COLD HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23111-1631
Mailing Address - Country:US
Mailing Address - Phone:804-746-9055
Mailing Address - Fax:804-746-4476
Practice Address - Street 1:7571 COLD HARBOR RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-1631
Practice Address - Country:US
Practice Address - Phone:804-746-9055
Practice Address - Fax:804-746-4476
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG42914Medicare UPIN