Healthcare Provider Details

I. General information

NPI: 1710946280
Provider Name (Legal Business Name): RODNEY L LUPARDUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 WEST US HIGHWAY 40
TROY IL
62294
US

IV. Provider business mailing address

6810 STATE ROUTE 162 BOX 215
MARYVILLE IL
62062-8501
US

V. Phone/Fax

Practice location:
  • Phone: 618-391-5065
  • Fax: 618-667-2779
Mailing address:
  • Phone: 618-391-6405
  • Fax: 618-288-4088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036085633
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: