MEDICARE: VINCENT LUSTIG PH.D., CCC-A

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	231H00000X	Audiologist	A0063	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1022588	OTHER	WV	WORKER'S COMP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164648424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VINCENT LUSTIG PH.D., CCC-A

Provider Business Mailing Address
First Line	:	5006 RENARD ST
Second Line	:
City	:	SISSONVILLE
State	:	WV
Zip	:	25320-9623
Country	:	US
Telephone Number	:	304-988-1760
Fax Number	:

Provider Business Practice Location Address
First Line	:	2205 WASHINGTON ST E
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25311-2218
Country	:	US
Telephone Number	:	304-345-8522
Fax Number	:	304-344-5305

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

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	07/09/2007

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