Healthcare Provider Details

I. General information

NPI: 1225061187
Provider Name (Legal Business Name): FELIPE EVANGELISTA JUGO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

401 6TH AVE STE 304B
MONTGOMERY WV
25136-2116
US

IV. Provider business mailing address

PO BOX 450 401 SIXTH AVE SUITE 304B
MONTGOMERY WV
25136-0450
US

V. Phone/Fax

Practice location:
  • Phone: 304-442-5231
  • Fax:
Mailing address:
  • Phone: 304-442-5231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10343
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: