Provider Demographics
NPI:1770541039
Name:LUPO, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LUPO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5171
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91305-5171
Mailing Address - Country:US
Mailing Address - Phone:818-847-3200
Mailing Address - Fax:818-847-3205
Practice Address - Street 1:501 SO BUENA VISTA ST
Practice Address - Street 2:5TH FLOOR NORTH TOWER
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505
Practice Address - Country:US
Practice Address - Phone:818-847-3280
Practice Address - Fax:818-847-3205
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68074208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG68074OtherLICENSE
CAG68074OtherLICENSE
F10223Medicare UPIN
CAOOG68074Medicare ID - Type Unspecified