Provider Demographics
NPI:1811007321
Name:CUPERO, TIMOTHY M (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:M
Last Name:CUPERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:RCS PROVIDER ENROLLMENT
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:2600 GREENBUSH STREET
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2479
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-7625
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35608207Y00000X
IN01063056A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200866630Medicaid
IN000000526754OtherANTHEM PROVIDER NUMBER
IN815500E9Medicare PIN
INP00414700Medicare PIN