Provider Demographics
NPI:1114127404
Name:LUGO, MIRIAN DOLORES (MD)
Entity Type:Individual
Prefix:
First Name:MIRIAN
Middle Name:DOLORES
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 1:344 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-2619
Mailing Address - Country:US
Mailing Address - Phone:973-435-4545
Mailing Address - Fax:973-928-1899
Practice Address - Street 1:344 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2619
Practice Address - Country:US
Practice Address - Phone:973-435-4545
Practice Address - Fax:973-928-1899
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08563400208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics