Healthcare Provider Details

I. General information

NPI: 1295979300
Provider Name (Legal Business Name): KATHARYN DESA LUPO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHARYN DESA FREUND

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 02/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 RAYMOND DR
NAPERVILLE IL
60563-9789
US

IV. Provider business mailing address

636 RAYMOND DR
NAPERVILLE IL
60563-9789
US

V. Phone/Fax

Practice location:
  • Phone: 630-922-2350
  • Fax: 630-922-2070
Mailing address:
  • Phone: 630-922-2350
  • Fax: 630-922-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036138404
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD448210
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036138404
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier036138404
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 2
Identifier920540
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerMEDICARE PTAN GROUP
# 3
IdentifierF400228991
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerMEDICARE PTAN INDIVIDUAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: