Provider Demographics
NPI:1700893625
Name:RUPP, RICHARD EARL (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:EARL
Last Name:RUPP
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 1:400 HARBORSIDE DRIVE
Mailing Address - Street 2:ISLAND PEDIATRICS SUITE 120
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555
Mailing Address - Country:US
Mailing Address - Phone:409-747-7334
Mailing Address - Fax:409-747-9252
Practice Address - Street 1:400 HARBORSIDE DRIVE
Practice Address - Street 2:SUITE 120
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555
Practice Address - Country:US
Practice Address - Phone:409-747-7334
Practice Address - Fax:409-747-9252
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ93162080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX13519004Medicaid
G10869Medicare UPIN