Provider Demographics
NPI:1760688006
Name:LUGO, LYDIA M (MD)
Entity type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:M
Last Name:LUGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 AVE GEN VALERO
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-4893
Mailing Address - Country:US
Mailing Address - Phone:787-860-0075
Mailing Address - Fax:787-863-6246
Practice Address - Street 1:375 AVE GEN VALERO
Practice Address - Street 2:SUITE 105
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-4893
Practice Address - Country:US
Practice Address - Phone:787-860-0075
Practice Address - Fax:787-863-6246
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8428174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR82044Medicare ID - Type Unspecified
PRD34225Medicare UPIN