Healthcare Provider Details

I. General information

NPI: 1932736865
Provider Name (Legal Business Name): CONNIE JANE LAGO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9598 US HIGHWAY 301 S
RIVERVIEW FL
33578-5429
US

IV. Provider business mailing address

151 SOUTHHALL LN STE 300
MAITLAND FL
32751-7172
US

V. Phone/Fax

Practice location:
  • Phone: 866-400-3376
  • Fax:
Mailing address:
  • Phone: 866-400-3376
  • Fax: 407-650-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME167839
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: