Provider Demographics
NPI:1962650853
Name:LUPTAK, IVAN JR (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:LUPTAK
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:801 ALBANY STREET
Mailing Address - Street 2:FL GROUND
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119
Mailing Address - Country:US
Mailing Address - Phone:617-414-5405
Mailing Address - Fax:617-414-6031
Practice Address - Street 1:732 HARRISON AVE
Practice Address - Street 2:PRESTON 3RD FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2309
Practice Address - Country:US
Practice Address - Phone:617-638-7490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2019-12-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA237871207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400116040Medicare PIN