Provider Demographics
NPI:1346449949
Name:MARY L. PUISSEGUR LUPO
Entity Type:Organization
Organization Name:MARY L. PUISSEGUR LUPO
Other - Org Name:LUPO CENTER FOR AESTHETIC & GENERAL DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUPO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-777-3047
Mailing Address - Street 1:145 ROBERT E LEE BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70124-2552
Mailing Address - Country:US
Mailing Address - Phone:504-777-3047
Mailing Address - Fax:504-288-1535
Practice Address - Street 1:145 ROBERT E LEE BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70124-2552
Practice Address - Country:US
Practice Address - Phone:504-777-3047
Practice Address - Fax:504-288-1535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5F918Medicare PIN