Provider Demographics
NPI:1487680476
Name:LUGO, IVELISSE (MD)
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
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 1:1206 S F ST
Mailing Address - Street 2:STE 1
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-6783
Mailing Address - Country:US
Mailing Address - Phone:956-444-0844
Mailing Address - Fax:956-444-0845
Practice Address - Street 1:1206 S F ST
Practice Address - Street 2:STE 1
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-6783
Practice Address - Country:US
Practice Address - Phone:956-444-0844
Practice Address - Fax:956-444-0845
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX044809403Medicaid
TX104297003Medicaid
TX84Z082Medicare PIN
TX104297003Medicaid
TX8G6781Medicare PIN