Provider Demographics
NPI:1174231674
Name:LUGO, ITZA
Entity type:Individual
Prefix:
First Name:ITZA
Middle Name:
Last Name:LUGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-1123
Mailing Address - Country:US
Mailing Address - Phone:201-667-9161
Mailing Address - Fax:
Practice Address - Street 1:181 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:CLIFFSIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07010-1123
Practice Address - Country:US
Practice Address - Phone:201-667-9161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJL91403776552842172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver