Provider Demographics
NPI:1932736865
Name:LAGO, CONNIE JANE (MD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:JANE
Last Name:LAGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E PETTIGREW ST APT 527
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-4878
Mailing Address - Country:US
Mailing Address - Phone:215-760-1446
Mailing Address - Fax:
Practice Address - Street 1:234 CROOKED CREEK PKWY STE 300
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-8507
Practice Address - Country:US
Practice Address - Phone:919-684-3432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME167839207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program