Provider Demographics
NPI:1336178169
Name:KUPERMAN, ILAN (MD)
Entity Type:Individual
Prefix:
First Name:ILAN
Middle Name:
Last Name:KUPERMAN
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 1:3525 DEL MAR HEIGHTS RD
Mailing Address - Street 2:#379
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2122
Mailing Address - Country:US
Mailing Address - Phone:949-851-1550
Mailing Address - Fax:
Practice Address - Street 1:4321 BIRCH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1923
Practice Address - Country:US
Practice Address - Phone:949-851-1550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87018207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H17189Medicare UPIN