Basic Information
| Provider Information | |||||||||
| NPI: | 1023118189 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUPU | ||||||||
| FirstName: | MIHAELA | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23300 ECORSE ROAD | ||||||||
| Address2: | |||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481801768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132919500 | ||||||||
| FaxNumber: | 3132916694 | ||||||||
| Practice Location | |||||||||
| Address1: | 18181 OAKWOOD BLVD | ||||||||
| Address2: | STE 208 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132715670 | ||||||||
| FaxNumber: | 3132711053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 02/19/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ML068630 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110H248450 | 01 | MI | BCBS MI | OTHER | 4081722 | 05 | MI | MEDICAID | 4081722-10 | 05 | MI | MEDICAID |