Basic Information
| Provider Information | |||||||||
| NPI: | 1952461204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUPER | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1514 JEFFERSON HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048424000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2750 EAST GAUSE BLVD. | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856393777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2006 | ||||||||
| LastUpdateDate: | 02/23/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 266 | AL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | DPM.PD314R | LA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 3354056 | 05 | TN | MEDICAID | 51524600 | 01 | AL | BCBS | OTHER | 1888214 | 05 | LA | MEDICAID | 02783285 | 05 | MS | MEDICAID |