Provider Demographics
NPI:1932267606
Name:KUPPERBERG, JERALD IVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JERALD
Middle Name:IVAN
Last Name:KUPPERBERG
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 1:54 HOWARD HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:FOSTER
Mailing Address - State:RI
Mailing Address - Zip Code:02825
Mailing Address - Country:US
Mailing Address - Phone:401-397-4638
Mailing Address - Fax:401-397-4638
Practice Address - Street 1:54 HOWARD HILL ROAD
Practice Address - Street 2:
Practice Address - City:FOSTER
Practice Address - State:RI
Practice Address - Zip Code:02825
Practice Address - Country:US
Practice Address - Phone:401-397-4638
Practice Address - Fax:401-397-4638
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD05404208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
5352215OtherAETNA
406111OtherTUFTS
RI8604Medicaid
1200196OtherUNITED HEALTH
RI8604Medicaid