Provider Demographics
NPI:1134180029
Name:LUPOLD, GEORGETTA D (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGETTA
Middle Name:D
Last Name:LUPOLD
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:CREDENTIALS DEPT
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:529 TERRY REILEY WAY
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-1774
Practice Address - Country:US
Practice Address - Phone:570-624-4444
Practice Address - Fax:570-624-4445
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD016590E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000687355Medicaid
PA079779Medicare ID - Type Unspecified
B35178Medicare UPIN