Provider Demographics
NPI:1033537857
Name:LUGO, CHARLES JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JONATHAN
Last Name:LUGO
Suffix:
Gender:M
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8460
Mailing Address - Country:US
Mailing Address - Phone:631-444-5400
Mailing Address - Fax:316-444-7538
Practice Address - Street 1:101 NICOLLS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-2118
Practice Address - Country:US
Practice Address - Phone:631-444-5400
Practice Address - Fax:631-444-7538
Is Sole Proprietor?:No
Enumeration Date:2014-03-29
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3127522085R0202X
MN765542085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology