Provider Demographics
NPI:1972213791
Name:LUGO, SHANTELL
Entity Type:Individual
Prefix:
First Name:SHANTELL
Middle Name:
Last Name:LUGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8215 SW 72ND AVE APT 1318
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-7871
Mailing Address - Country:US
Mailing Address - Phone:786-992-7036
Mailing Address - Fax:
Practice Address - Street 1:8215 SW 72ND AVE APT 1318
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-7871
Practice Address - Country:US
Practice Address - Phone:786-992-7036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA888552081N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular MedicineGroup - Single Specialty