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General NPI Number Information
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NPI Number | 1720177694
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Entity Type | Organization
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Legal Business Name | HAVERSTRAW FAMILY PRACTICE, P.C.
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Dates
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Enumeration Date | 10/11/2006
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Last Update Date | 05/07/2008
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Provider Practice Location Address
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Address Line | 61 NEW MAIN ST
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City | HAVERSTRAW
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State | NY
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Zip | 10927-1813
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Country | US
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Telephone | 845-942-4512
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Fax | 845-942-4514
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Provider Business Mailing Address
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Address Line | PO BOX 380 61 NEW MAIN STREET
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City | HAVERSTRAW
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State | NY
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Zip | 10927-0380
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Country | US
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Telephone | 845-942-4512
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Fax | 845-942-4514
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Authorized Official
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Title or Position | PRESIDENT
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Name | JORGE ERNESTO LUGO
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Credential | M.D.
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Telephone | 845-942-4512
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 208332
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License Number State | NY
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