Basic Information
| Provider Information | |||||||||
| NPI: | 1336179357 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCIANO-PEREZ | ||||||||
| FirstName: | ERNESTO | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5838 HARBOUR VIEW BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234352663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576735680 | ||||||||
| FaxNumber: | 7574833075 | ||||||||
| Practice Location | |||||||||
| Address1: | 5838 HARBOUR VIEW BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234352663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576735680 | ||||||||
| FaxNumber: | 7574833075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 0101046224 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 006405231 | 05 | VA | MEDICAID | 200028240 | 01 | VA | MEDICARE RR | OTHER |