MEDICARE: DR. MARCY ANN WITKIN LUPO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY 17157	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154387843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARCY ANN WITKIN LUPO

Provider Business Mailing Address
First Line	:	3435 BRANDYWINE ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-5605
Country	:	US
Telephone Number	:	858-270-0787
Fax Number	:	858-274-5541

Provider Business Practice Location Address
First Line	:	3435 BRANDYWINE ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-5605
Country	:	US
Telephone Number	:	858-270-0787
Fax Number	:	858-274-5541

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2006
Last Update Date	:	07/09/2007

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