Provider Demographics
NPI:1508957127
Name:RUPP, LIEU (MD)
Entity Type:Individual
Prefix:
First Name:LIEU
Middle Name:
Last Name:RUPP
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 1:4440 BROCKTON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4026
Mailing Address - Country:US
Mailing Address - Phone:951-369-0138
Mailing Address - Fax:951-369-1028
Practice Address - Street 1:4440 BROCKTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4026
Practice Address - Country:US
Practice Address - Phone:951-369-0138
Practice Address - Fax:951-369-1028
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64515174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G645150Medicare ID - Type Unspecified
CAE73348Medicare UPIN