Provider Demographics
NPI:1033635271
Name:ERIC LUP-SING LO M. D., P.A.
Entity type:Organization
Organization Name:ERIC LUP-SING LO M. D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:S
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-316-0955
Mailing Address - Street 1:305 MEMORIAL MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5168
Mailing Address - Country:US
Mailing Address - Phone:386-672-1023
Mailing Address - Fax:386-263-2996
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5168
Practice Address - Country:US
Practice Address - Phone:386-672-1023
Practice Address - Fax:386-263-2996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8346100Medicaid