Provider Demographics
NPI:1952509457
Name:KUPER, ELISABETH MARTA (MD)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:MARTA
Last Name:KUPER
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:PO BOX 1292
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443-1292
Mailing Address - Country:US
Mailing Address - Phone:970-668-1791
Mailing Address - Fax:970-262-2196
Practice Address - Street 1:265 TANGLEWOOD LN, E1
Practice Address - Street 2:
Practice Address - City:SILVERTHORNE
Practice Address - State:CO
Practice Address - Zip Code:80498
Practice Address - Country:US
Practice Address - Phone:970-468-1003
Practice Address - Fax:970-262-2196
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMR-0938207Q00000X
IDM-10576207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1196321OtherMEDICARE PTAN
ID807773500Medicaid