Provider Demographics
NPI:1295979300
Name:LUPO, KATHARYN DESA (MD)
Entity type:Individual
Prefix:MS
First Name:KATHARYN
Middle Name:DESA
Last Name:LUPO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHARYN
Other - Middle Name:DESA
Other - Last Name:FREUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:636 RAYMOND DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-9789
Mailing Address - Country:US
Mailing Address - Phone:630-922-2350
Mailing Address - Fax:630-922-2070
Practice Address - Street 1:636 RAYMOND DR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-9789
Practice Address - Country:US
Practice Address - Phone:630-922-2350
Practice Address - Fax:630-922-2070
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138404208000000X, 207R00000X
PAMD448210208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036138404Medicaid
IL920540OtherMEDICARE PTAN GROUP
ILF400228991OtherMEDICARE PTAN INDIVIDUAL