MEDICARE: DR. LUPO TANJUAKIO CARLOTA JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	MD0000012972	TN

General Provider Information

NPI Number	:	1235176041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUPO TANJUAKIO CARLOTA JR. M.D.

Provider Business Mailing Address
First Line	:	9749 GREEN SPRUCE DR
Second Line	:
City	:	LAKELAND
State	:	TN
Zip	:	38002-9341
Country	:	US
Telephone Number	:	901-828-4795
Fax Number	:

Provider Business Practice Location Address
First Line	:	9749 GREEN SPRUCE DR
Second Line	:
City	:	LAKELAND
State	:	TN
Zip	:	38002-9341
Country	:	US
Telephone Number	:	901-821-8595
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	08/05/2021

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