Provider Demographics
NPI:1962025239
Name:LUPOLT, ALEX (OD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:LUPOLT
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 1:1331 COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-8187
Mailing Address - Country:US
Mailing Address - Phone:570-765-1636
Mailing Address - Fax:
Practice Address - Street 1:4504 WESTBRANCH HWY
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-6605
Practice Address - Country:US
Practice Address - Phone:570-768-4970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003669152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist