Provider Demographics
NPI:1720177694
Name:HAVERSTRAW FAMILY PRACTICE, P.C.
Entity Type:Organization
Organization Name:HAVERSTRAW FAMILY PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:ERNESTO
Authorized Official - Last Name:LUGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-942-4512
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:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY396995OtherCONNECTICARE
NY46V621OtherEMPIRE BC/BS
NY01814819Medicaid
NY172321POtherHIP
NY005720OtherCOMMUNITY CHOICE
NY1000000194OtherAFFINITY
NY5997592OtherGHI
NY134973OtherAETNA
NY4C5847OtherHEALTHNET
NY040426012056OtherFIDELIS
NY221824OtherWELLCARE
NY393729OtherMVP
NYP2543357OtherOXFORD
NY134973OtherAETNA
NY4C5847OtherHEALTHNET