Healthcare Provider Details

I. General information

NPI: 1962626705
Provider Name (Legal Business Name): ETTIENNE LUGO DELGADO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE LUIS MUNOZ RIVERA 5
CAMUY PR
00627-0000
US

IV. Provider business mailing address

4 CALLE HOLLYWOOD DR URB. HOLLYWOOD ESTATES BO. QUEBRADA ARENAS
SAN JUAN PR
00926
US

V. Phone/Fax

Practice location:
  • Phone: 787-262-1486
  • Fax: 787-262-1486
Mailing address:
  • Phone: 787-262-1486
  • Fax: 787-262-1486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number573
License Number StatePR

VIII. Authorized Official

Name: DR. ETTIENNE LUGO
Title or Position: DOCTOR OF OPTOMETRY
Credential: O.D.
Phone: 787-262-1486