Healthcare Provider Details

I. General information

NPI: 1336371509
Provider Name (Legal Business Name): MACKENZIE ELIZABETH LUPOV M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 2ND ST
BLOOMINGTON IN
47403-2317
US

IV. Provider business mailing address

PO BOX 1329
BLOOMINGTON IN
47402-1329
US

V. Phone/Fax

Practice location:
  • Phone: 812-676-4542
  • Fax: 812-676-4106
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number11014966A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11014966A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: