1700104619 NPI number — KERWIN JOEL ANTONIO LUPISAN MD

Table of content: KERWIN JOEL ANTONIO LUPISAN MD (NPI 1700104619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700104619 NPI number — KERWIN JOEL ANTONIO LUPISAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUPISAN
Provider First Name:
KERWIN JOEL
Provider Middle Name:
ANTONIO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LUPISAN
Provider Other First Name:
KERWIN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1700104619
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4590 DRESSLER RD NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44718-2546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-484-1607
Provider Business Mailing Address Fax Number:
330-484-2943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4590 DRESSLER RD NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44718-2546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-484-1607
Provider Business Practice Location Address Fax Number:
330-484-2943
Provider Enumeration Date:
05/17/2010

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: 207Q00000X , with the licence number:  35-121969 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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