Provider Demographics
NPI:1124480611
Name:LUJAN HERNANDEZ, JORGE R (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:R
Last Name:LUJAN HERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY STREET, FL 3 STE 3
Practice Address - Street 2:SHAPIRO BLDG.
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-638-8419
Practice Address - Fax:617-414-0201
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA279398208200000X, 2086S0122X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110119188AMedicaid