Healthcare Provider Details

I. General information

NPI: 1811969298
Provider Name (Legal Business Name): WILFRED AMISCUA LUMBANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HITCHCOCK WAY # 03104000
MANCHESTER NH
03104-4125
US

IV. Provider business mailing address

PO BOX 810
HANOVER NH
03755-0810
US

V. Phone/Fax

Practice location:
  • Phone: 603-695-2500
  • Fax:
Mailing address:
  • Phone: 603-308-1467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number48569
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD0000045837
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number39108
License Number StateNH
# 4
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number48569
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: