Healthcare Provider Details

I. General information

NPI: 1497911804
Provider Name (Legal Business Name): BRIAN LUGO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 09/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 S FAIR OAKS AVE SUITE 101
PASADENA CA
91105-2622
US

IV. Provider business mailing address

1044 S FAIR OAKS AVE SUITE 101
PASADENA CA
91105-2622
US

V. Phone/Fax

Practice location:
  • Phone: 626-768-4415
  • Fax: 626-768-4421
Mailing address:
  • Phone: 714-222-0063
  • Fax: 626-768-4421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberA87704
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA8704
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: