Healthcare Provider Details

I. General information

NPI: 1033537857
Provider Name (Legal Business Name): CHARLES JONATHAN LUGO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2014
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NICOLLS RD
STONY BROOK NY
11794-2118
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11794-8460
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-5400
  • Fax: 631-444-7538
Mailing address:
  • Phone: 631-444-5400
  • Fax: 316-444-7538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number312752
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number76554
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME144236
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberC3181
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036177510
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: