Provider Demographics
NPI:1073601035
Name:LUGO-ESCHENWALD, VIVIAN L (MD)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:L
Last Name:LUGO-ESCHENWALD
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:PO BOX 17334
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1334
Mailing Address - Country:US
Mailing Address - Phone:703-443-6717
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:2000 N BEAUREGARD ST
Practice Address - Street 2:SUITE 330
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1748
Practice Address - Country:US
Practice Address - Phone:703-370-2400
Practice Address - Fax:703-370-7214
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049923207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1073601035Medicaid
VAF67102Medicare UPIN
VA1073601035Medicaid