Provider Demographics
NPI:1982994745
Name:KUPPUSAMY, AHDEV (MD)
Entity Type:Individual
Prefix:
First Name:AHDEV
Middle Name:
Last Name:KUPPUSAMY
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 1:3370 S MERCY RD STE 321
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-0414
Mailing Address - Country:US
Mailing Address - Phone:480-550-9393
Mailing Address - Fax:480-999-3375
Practice Address - Street 1:3370 S MERCY RD STE 321
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0414
Practice Address - Country:US
Practice Address - Phone:480-550-9393
Practice Address - Fax:480-999-3375
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44807207L00000X, 208VP0014X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ627938Medicaid
AZ627938Medicaid
AZZ146635Medicare PIN