Provider Demographics
NPI:1063644854
Name:LUPO, CHARLES L (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
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 1:27650 FERRY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3845
Mailing Address - Country:US
Mailing Address - Phone:630-225-2663
Mailing Address - Fax:
Practice Address - Street 1:27650 FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3845
Practice Address - Country:US
Practice Address - Phone:630-225-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT195527207X00000X
IL036137806207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE PTAN GROUP
ILF400226647OtherMEDICARE PTAN INDIVIDUAL