Provider Demographics
NPI:1689382020
Name:LUPKES, SAMUEL ELIJAH (OD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ELIJAH
Last Name:LUPKES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 1ST AVE NE APT 327
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-2904
Mailing Address - Country:US
Mailing Address - Phone:916-747-0029
Mailing Address - Fax:
Practice Address - Street 1:300 WESTERN AVE NW STE 100 1/2
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-4528
Practice Address - Country:US
Practice Address - Phone:916-747-0029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3832152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist