Provider Demographics
NPI:1689770646
Name:LUPENA, MYRNA R (MD)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:R
Last Name:LUPENA
Suffix:
Gender:F
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:CHICAGO DEPARTMENT OF PUBLIC HEALTH
Mailing Address - Street 2:333 S STATE STREET REVENUE #200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604
Mailing Address - Country:US
Mailing Address - Phone:312-747-9443
Mailing Address - Fax:312-747-9447
Practice Address - Street 1:CHICAGO DEPARTMENT OF PUBLIC HEALTH
Practice Address - Street 2:333 S STATE STREET REVENUE #200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604
Practice Address - Country:US
Practice Address - Phone:312-747-9443
Practice Address - Fax:312-747-9447
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPAYEE #2Medicaid
D16706Medicare UPIN