Healthcare Provider Details

I. General information

NPI: 1013209303
Provider Name (Legal Business Name): FABIAN LUGO MD, A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 05/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 S COLLEGE RD SUITE 107
LAFAYETTE LA
70503-3060
US

IV. Provider business mailing address

PO BOX 52465
LAFAYETTE LA
70505-2465
US

V. Phone/Fax

Practice location:
  • Phone: 337-989-9971
  • Fax: 337-989-9986
Mailing address:
  • Phone: 337-989-9971
  • Fax: 337-989-9986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number020740
License Number StateLA

VIII. Authorized Official

Name: DR. FABIAN LUGO
Title or Position: PHYSICIAN
Credential: M.D.,
Phone: 337-989-9971