Provider Demographics
NPI:1366646572
Name:LUPIN, SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:LUPIN
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 1:6 LYNHAVEN CT
Mailing Address - Street 2:
Mailing Address - City:MONSEY
Mailing Address - State:NY
Mailing Address - Zip Code:10952-2411
Mailing Address - Country:US
Mailing Address - Phone:845-356-9433
Mailing Address - Fax:845-371-5897
Practice Address - Street 1:3131 KINGS HWY
Practice Address - Street 2:SUITE B1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2644
Practice Address - Country:US
Practice Address - Phone:845-356-9433
Practice Address - Fax:845-371-5897
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138014174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP770149OtherOXFORD
NY0035751OtherGHI
NY31A671OtherBLUE CROSS BLUE SHIELD
NY00799555Medicaid
NYNZ8794OtherHEALTHNET
NY31A671Medicare PIN
NYNZ8794OtherHEALTHNET