Provider Demographics
NPI:1194704320
Name:LUGO, LISSETTE (MD)
Entity type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:LUGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 BROADWAY
Mailing Address - Street 2:SUITE 506
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-7001
Mailing Address - Country:US
Mailing Address - Phone:212-302-4399
Mailing Address - Fax:212-302-2582
Practice Address - Street 1:1 CLARA MAASS DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-3550
Practice Address - Country:US
Practice Address - Phone:212-302-4399
Practice Address - Fax:212-302-2582
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224552-1207L00000X
NJ25MA07961400207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ221948732001OtherTRICARE
NJ0088064Medicaid
NY02694668Medicaid
NYA400096928Medicare PIN
NJ096872Medicare ID - Type Unspecified
NJ0088064Medicaid