Provider Demographics
NPI:1417055674
Name:LUPOW, JASON BRETT (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:BRETT
Last Name:LUPOW
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 1:10 MARK DR
Mailing Address - Street 2:
Mailing Address - City:RYE BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:10573-1411
Mailing Address - Country:US
Mailing Address - Phone:917-704-3356
Mailing Address - Fax:
Practice Address - Street 1:1030 W BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-3328
Practice Address - Country:US
Practice Address - Phone:914-777-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08061900207P00000X
NY237641207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00391144OtherRAILROAD
NJI68233Medicare UPIN
NJ107107Medicare PIN