Provider Demographics
NPI:1952461204
Name:LUPER, KEITH J (DPM)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:J
Last Name:LUPER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:2750 EAST GAUSE BLVD.
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461
Practice Address - Country:US
Practice Address - Phone:985-639-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-09
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL266213E00000X
LADPM.PD314R213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3354056Medicaid
AL51524600OtherBCBS
LA1888214Medicaid
MS02783285Medicaid
V00724Medicare UPIN
LA4M4427061Medicare PIN
051554937Medicare ID - Type Unspecified
TN3354056Medicare ID - Type Unspecified