MEDICARE: DR. DAVID MICHAEL LUSTIG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	ME 128530	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	340018922	OTHER	GA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	434494	OTHER	VA	ANTHEM
3	542025035	OTHER	VA	TRICARE
4	7503962	OTHER	VA	VIRGINIA PREMIER
5	0380470	OTHER	VI	CIGNA
6	3433588	OTHER	VA	AETNA
7	2127380	OTHER	VA	MDIPA
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093896367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID MICHAEL LUSTIG M.D.

Provider Business Mailing Address
First Line	:	13933 17TH ST
Second Line	:	SUITE 201
City	:	DADE CITY
State	:	FL
Zip	:	33525-4604
Country	:	US
Telephone Number	:	352-437-4505
Fax Number	:	352-437-4709

Provider Business Practice Location Address
First Line	:	13933 17TH ST
Second Line	:	SUITE 201
City	:	DADE CITY
State	:	FL
Zip	:	33525-4604
Country	:	US
Telephone Number	:	352-437-4505
Fax Number	:	352-437-4709

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	02/01/2017

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Directions to “ DR. DAVID MICHAEL LUSTIG M.D.” Practice Location

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