1285745158 NPI number — STEPHEN R SHUPUT MD

Table of content: STEPHEN R SHUPUT MD (NPI 1285745158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285745158 NPI number — STEPHEN R SHUPUT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHUPUT
Provider First Name:
STEPHEN
Provider Middle Name:
R
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285745158
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43314 BANDA TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREMONT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94539-5660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-991-6704
Provider Business Mailing Address Fax Number:
408-444-8845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43314 BANDA TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREMONT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94539-5660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-991-6704
Provider Business Practice Location Address Fax Number:
408-444-8845
Provider Enumeration Date:
08/31/2006

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: 207L00000X , with the licence number:  MD27419 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 82-169038-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: G52161 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8492795 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 870545614SH1 . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: PRA05848 . This is a "MOLINA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107005104101 . This is a "IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 2090168 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 8597445 . This is a "WORKERS COMP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: QM0000075886 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 003075300 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 006393 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37817 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 108049100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00611182 . This is a "RR MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 100501223 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1502954 . This is a "UMWA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 36407 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 53268 . This is a "HEALTHY U" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 820838 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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