Basic Information
| Provider Information | |||||||||
| NPI: | 1669679353 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UPTON | ||||||||
| FirstName: | MONIQUE | ||||||||
| MiddleName: | LASHAWNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9671 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321209671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866767130 | ||||||||
| FaxNumber: | 3866767125 | ||||||||
| Practice Location | |||||||||
| Address1: | 1340 RIDGEWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLY HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321172320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866767175 | ||||||||
| FaxNumber: | 3866767134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 05/09/2019 | ||||||||
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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 | 2084P0800X | ME116163 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | K226510 | 01 | KY | MEDICARE | OTHER | 14M8T | 01 | FL | BCBS | OTHER | 7100148830 | 05 | KY | MEDICAID | 006241300 | 05 | FL | MEDICAID | 1669679353 | 01 | FL | TRICARE | OTHER |