Healthcare Provider Details

I. General information

NPI: 1366487308
Provider Name (Legal Business Name): JEFFREY ROBERT LUPOVITCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29927 SIX MILE RD
LIVONIA MI
48152
US

IV. Provider business mailing address

29927 SIX MILE RD
LIVONIA MI
48152
US

V. Phone/Fax

Practice location:
  • Phone: 734-522-0800
  • Fax: 734-522-1236
Mailing address:
  • Phone: 734-522-0800
  • Fax: 734-522-1236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301079764
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: