Provider Demographics
NPI:1548486699
Name:RUPP, SONIA N (MD)
Entity type:Individual
Prefix:DR
First Name:SONIA
Middle Name:N
Last Name:RUPP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:155 HWY 50
Practice Address - Street 2:
Practice Address - City:STATELINE
Practice Address - State:NV
Practice Address - Zip Code:89449
Practice Address - Country:US
Practice Address - Phone:775-589-8946
Practice Address - Fax:775-588-1354
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA558522084P0804X, 2084P0804X
NV97142084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1548486699Medicaid
CA00A558520Medicare PIN