Healthcare Provider Details

I. General information

NPI: 1033635271
Provider Name (Legal Business Name): ERIC LUP-SING LO M. D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MEMORIAL MEDICAL PKWY
DAYTONA BEACH FL
32117-5168
US

IV. Provider business mailing address

305 MEMORIAL MEDICAL PKWY
DAYTONA BEACH FL
32117-5168
US

V. Phone/Fax

Practice location:
  • Phone: 386-672-1023
  • Fax: 386-263-2996
Mailing address:
  • Phone: 386-672-1023
  • Fax: 386-263-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: YVETTE S ANDERSON
Title or Position: CONSULTING MANAGER
Credential:
Phone: 386-316-0955