Provider Demographics
NPI:1700145182
Name:KUPERSTOCK, JACOB EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:EDWIN
Last Name:KUPERSTOCK
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 1:3801 UNIVERSITY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2503
Mailing Address - Country:US
Mailing Address - Phone:703-383-8130
Mailing Address - Fax:703-383-7355
Practice Address - Street 1:3801 UNIVERSITY DR STE 300
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030
Practice Address - Country:US
Practice Address - Phone:703-383-8130
Practice Address - Fax:703-383-7355
Is Sole Proprietor?:No
Enumeration Date:2012-05-06
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA255486207Y00000X
VA0101266254207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology