Basic Information
| Provider Information | |||||||||
| NPI: | 1336371509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUPOV | ||||||||
| FirstName: | MACKENZIE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1329 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474021329 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 W 2ND ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474032317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126764542 | ||||||||
| FaxNumber: | 8126764106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2009 | ||||||||
| LastUpdateDate: | 11/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 11014966A | IN | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 11014966A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201074650 | 05 | IN | MEDICAID |