Healthcare Provider Details

I. General information

NPI: 1235176041
Provider Name (Legal Business Name): LUPO TANJUAKIO CARLOTA JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9749 GREEN SPRUCE DR
LAKELAND TN
38002-9341
US

IV. Provider business mailing address

9749 GREEN SPRUCE DR
LAKELAND TN
38002-9341
US

V. Phone/Fax

Practice location:
  • Phone: 901-821-8595
  • Fax:
Mailing address:
  • Phone: 901-828-4795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD0000012972
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: