Provider Demographics
NPI:1104153790
Name:LUGO, MIGUEL ANGEL (IDC)
Entity type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:ANGEL
Last Name:LUGO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2907 MAKUU LOOP
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-3629
Mailing Address - Country:US
Mailing Address - Phone:808-234-3685
Mailing Address - Fax:
Practice Address - Street 1:USS LOS ANGELES (SSN 688)
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96601
Practice Address - Country:US
Practice Address - Phone:808-590-6849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman