Provider Demographics
NPI:1336371509
Name:LUPOV, MACKENZIE ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ELIZABETH
Last Name:LUPOV
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:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2317
Practice Address - Country:US
Practice Address - Phone:812-676-4542
Practice Address - Fax:812-676-4106
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11014966A208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201074650Medicaid
INM400072252Medicare PIN