Provider Demographics
NPI:1649443821
Name:LUGO, JORGE ERNESTO (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ERNESTO
Last Name:LUGO
Suffix:
Gender:M
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:PO BOX 380
Mailing Address - Street 2:61 NEW MAIN STREET
Mailing Address - City:HAVERSTRAW
Mailing Address - State:NY
Mailing Address - Zip Code:10927-0380
Mailing Address - Country:US
Mailing Address - Phone:845-942-4512
Mailing Address - Fax:845-942-4514
Practice Address - Street 1:61 NEW MAIN ST
Practice Address - Street 2:61 NEW MAIN STREET
Practice Address - City:HAVERSTRAW
Practice Address - State:NY
Practice Address - Zip Code:10927-1813
Practice Address - Country:US
Practice Address - Phone:845-942-4512
Practice Address - Fax:845-942-4514
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1000000194OtherAFFINITY
NY01814819Medicaid
NY393729OtherMVP
NYP2543357OtherOXFORD
NY5997592OtherGHI
NY040426012056OtherFIDELIS
134973OtherAETNA
NY172321POtherHIP
NY221824OtherWELLCARE
NY46V621OtherEMPIRE BC/BS
NY4C5847OtherHEALTHNET
NY396995OtherCONNECTICARE
NY393729OtherMVP
NY11V505W341Medicare PIN