Provider Demographics
NPI:1366487308
Name:LUPOVITCH, JEFFREY ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ROBERT
Last Name:LUPOVITCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:29927 SIX MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152
Mailing Address - Country:US
Mailing Address - Phone:734-522-0800
Mailing Address - Fax:734-522-1236
Practice Address - Street 1:29927 SIX MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152
Practice Address - Country:US
Practice Address - Phone:734-522-0800
Practice Address - Fax:734-522-1236
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079764207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
381867275OtherHARRINGTON BENEFITS
MIJL079764OtherSTATE LICENSE
180F372960OtherBLUE CARE NETWORK
381867275OtherGREATLAKES
381867275OtherWPS TRICARE FOR LIFE
MI104933152Medicaid
381867275OtherAETNA
381867275OtherUNITED HEALTH CARE
MIOH24256OtherBLUE CROSS
381867275OtherCIGNA
381867275OtherGREAT LAKES
381867275OtherPPOM
180F372960OtherBLUE CARE NETWORK
381867275OtherPPOM
381867275OtherCIGNA
MIF37296006Medicare Oscar/Certification