Basic Information
| Provider Information | |||||||||
| NPI: | 1700205911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUPAK | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 CROSSLANDS RD | ||||||||
| Address2: | |||||||||
| City: | BENBROOK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761321007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014041220 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179262544 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0002X | R1942 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
No ID Information.