Provider Demographics
NPI:1942485099
Name:LUPA, MICHAEL DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:LUPA
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 1:2 PRINCESS RD STE E
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2320
Mailing Address - Country:US
Mailing Address - Phone:610-303-5163
Mailing Address - Fax:
Practice Address - Street 1:2 PRINCESS RD STE E
Practice Address - Street 2:
Practice Address - City:LAWRENCE TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08648-2320
Practice Address - Country:US
Practice Address - Phone:610-303-5163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09847400207Y00000X
PAMD457006207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ510172ZVKUOtherMEMBER PTAN