Provider Demographics
NPI:1710155593
Name:CUPP, SHANNON L (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:L
Last Name:CUPP
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 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2550 S PARKER RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1622
Practice Address - Country:US
Practice Address - Phone:303-636-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO34898207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01348986Medicaid
CO8909OtherKAISER COMMERCIAL NUMBER
CO8909OtherKAISER COMMERCIAL NUMBER
COF33587Medicare UPIN