Provider Demographics
NPI:1144315284
Name:LUPO, JOHN ALFRED (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ALFRED
Last Name:LUPO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-1689
Mailing Address - Country:US
Mailing Address - Phone:814-866-5559
Mailing Address - Fax:
Practice Address - Street 1:3901 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-1689
Practice Address - Country:US
Practice Address - Phone:814-866-5559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC005039L111N00000X
332B00000X, 247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019387450001Medicaid
PALU133922OtherPTAN
PALU133922OtherHIGHMARK
PA0019387450001Medicaid