Provider Demographics
NPI:1831108869
Name:JEFFREY B. PUPP
Entity Type:Organization
Organization Name:JEFFREY B. PUPP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:B
Authorized Official - Last Name:PUPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-343-8889
Mailing Address - Street 1:1602 DOCTORS CIR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7406
Mailing Address - Country:US
Mailing Address - Phone:910-343-8889
Mailing Address - Fax:910-343-9990
Practice Address - Street 1:1602 DOCTORS CIR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7406
Practice Address - Country:US
Practice Address - Phone:910-343-8889
Practice Address - Fax:910-343-9990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC449213ES0103X
NC230213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890231RMedicaid
NC2432650OtherMEDICARE PTAN
NCB1115OtherMEDCOST
NC0231ROtherBCBS NC
NCCC3025OtherRAILROAD MEDICARE PTAN
NC0231ROtherBCBS NC