Provider Demographics
NPI:1659378552
Name:JUPIN, MICHELLE RENEE (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:RENEE
Last Name:JUPIN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1779
Mailing Address - Country:US
Mailing Address - Phone:248-548-7363
Mailing Address - Fax:248-548-5304
Practice Address - Street 1:641 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1779
Practice Address - Country:US
Practice Address - Phone:248-548-7363
Practice Address - Fax:248-548-5304
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002054213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38-2469733OtherTAX ID FOR PRIMARY LOCATI
MI4856310140OtherBLUE CROSS BLUE SHIELD
MI4617312Medicaid
MI4856310140OtherBLUE CROSS BLUE SHIELD
MI4617312Medicaid