Provider Demographics
NPI:1477856631
Name:LUGO, MARESA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARESA
Middle Name:
Last Name:LUGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARESA
Other - Middle Name:
Other - Last Name:LUGO MONTALVO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:50 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-6300
Mailing Address - Country:US
Mailing Address - Phone:863-293-2107
Mailing Address - Fax:863-595-4227
Practice Address - Street 1:50 2ND ST SE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880
Practice Address - Country:US
Practice Address - Phone:863-293-2107
Practice Address - Fax:863-595-4227
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-09
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1411992084N0400X
VA01012493812084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLYUMLFOtherFLORIDA BLUE