Healthcare Provider Details

I. General information

NPI: 1285602987
Provider Name (Legal Business Name): HUMBERTO LUGO VICENTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 CALLE SANTA CRUZ SUITE 309, SANTA CRUZ MEDICAL BLDG.
BAYAMON PR
00961-6910
US

IV. Provider business mailing address

PO BOX 10426 CAPARRA HEIGHTS STATION
SAN JUAN PR
00922-0426
US

V. Phone/Fax

Practice location:
  • Phone: 787-786-3495
  • Fax: 787-720-6103
Mailing address:
  • Phone: 787-786-3495
  • Fax: 787-720-6103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number7214
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: