Provider Demographics
NPI:1184102253
Name:DA SILVA LUGO, IAN JARED
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:JARED
Last Name:DA SILVA LUGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 AVE MUNOZ RIVERA APT 707
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927-5002
Mailing Address - Country:US
Mailing Address - Phone:787-234-7950
Mailing Address - Fax:
Practice Address - Street 1:CENTRO MEDICO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921
Practice Address - Country:US
Practice Address - Phone:787-234-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR390200000X
390200000X
PR35536207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program