Provider Demographics
NPI:1861681975
Name:VICTOR LUGO MIRO MD PA
Entity Type:Organization
Organization Name:VICTOR LUGO MIRO MD PA
Other - Org Name:VICTOR IVAN LUGO-MIRO MD
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:I
Authorized Official - Last Name:LUGO MIRO
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:281-360-8501
Mailing Address - Street 1:3036 NORTHPARK DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-5114
Mailing Address - Country:US
Mailing Address - Phone:281-360-8501
Mailing Address - Fax:281-360-8617
Practice Address - Street 1:3036 NORTHPARK DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-5114
Practice Address - Country:US
Practice Address - Phone:281-360-8501
Practice Address - Fax:281-360-8617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6890207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080241501Medicaid
TXE42594Medicare UPIN
TX080241501Medicaid