Provider Demographics
NPI:1700205911
Name:CUPAK, MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CUPAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CROSSLANDS RD
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76132-1007
Mailing Address - Country:US
Mailing Address - Phone:801-404-1220
Mailing Address - Fax:
Practice Address - Street 1:1400 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-926-2544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR1942207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty