Provider Demographics
NPI:1316085368
Name:IRIZARRY LUGO, MARISEL (OD)
Entity type:Individual
Prefix:
First Name:MARISEL
Middle Name:
Last Name:IRIZARRY LUGO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 63
Mailing Address - Street 2:
Mailing Address - City:SABANA GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00637-0063
Mailing Address - Country:US
Mailing Address - Phone:787-487-0890
Mailing Address - Fax:787-264-3830
Practice Address - Street 1:SAN GERMAN MEDICAL PLAZA
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00638
Practice Address - Country:US
Practice Address - Phone:787-264-3830
Practice Address - Fax:787-264-3830
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR587152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR005-6662Medicare ID - Type UnspecifiedMEDICARE
PRP814Medicare UPIN
PR5-6662IRMedicare UPIN