1407122468 NPI number — JESSICA G CUPIDO DO

Table of content: JESSICA G CUPIDO DO (NPI 1407122468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407122468 NPI number — JESSICA G CUPIDO DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUPIDO
Provider First Name:
JESSICA
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOMES
Provider Other First Name:
JESSICA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407122468
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38135 MARKET SQ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZEPHYRHILLS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33542-7505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-284-2212
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 TOWN CENTER BLVD STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANDON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33511-2906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-284-2212
Provider Business Practice Location Address Fax Number:
813-377-1713
Provider Enumeration Date:
03/23/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  OS138898 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081P2900X , with the licence number: OS13898 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 023320500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".