MEDICARE: DR. ETTIENNE LUGO DELGADO O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	573	PR

General Provider Information

NPI Number	:	1982669750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ETTIENNE LUGO DELGADO O.D.

Provider Business Mailing Address
First Line	:	4 CALLE HOLLYWOOD DRIVE
Second Line	:	URB. HOLLYWOOD ESTATES
City	:	SAN JUAN
State	:	PR
Zip	:	00926
Country	:	US
Telephone Number	:	787-262-1486
Fax Number	:	787-262-1486

Provider Business Practice Location Address
First Line	:	CALLE LUIS MUNOZ RIVERA 5
Second Line	:	SUITE 2
City	:	CAMUY
State	:	PR
Zip	:	00627-0000
Country	:	US
Telephone Number	:	787-262-1486
Fax Number	:	787-262-1486

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	10/09/2012

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