Provider Demographics
NPI:1861456162
Name:KUPPUSAMI, MUTHUSAMI (MD)
Entity Type:Individual
Prefix:
First Name:MUTHUSAMI
Middle Name:
Last Name:KUPPUSAMI
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 1:109 WINDSOR CIR
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605-9324
Mailing Address - Country:US
Mailing Address - Phone:276-326-3356
Mailing Address - Fax:
Practice Address - Street 1:109 WINDSOR CIR
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-9324
Practice Address - Country:US
Practice Address - Phone:276-326-3356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV09769208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0124083000Medicaid
WV7304021Medicare ID - Type Unspecified
WV0124083000Medicaid