Provider Demographics
NPI:1962816876
Name:KNUPPENBURG, STEPHANIE AYITA (MD)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:AYITA
Last Name:KNUPPENBURG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:AVITA
Other - Last Name:JUGMOHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1094 MILITARY TRL
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7021
Mailing Address - Country:US
Mailing Address - Phone:561-622-6111
Mailing Address - Fax:552-159-9308
Practice Address - Street 1:4700 N CONGRESS AVE STE 103
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3284
Practice Address - Country:US
Practice Address - Phone:561-622-6111
Practice Address - Fax:855-215-9930
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105575207Q00000X, 390200000X
AZ54346207Q00000X
FLME150156207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ283134Medicaid