MEDICARE: DR. STUART A. LUSTBERG 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	207V00000X	Obstetrics & Gynecology Physician	182725	NY

General Provider Information

NPI Number	:	1528120102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STUART A. LUSTBERG M.D.

Provider Business Mailing Address
First Line	:	110 E MAIN ST
Second Line	:	SUITE 3
City	:	HUNTINGTON
State	:	NY
Zip	:	11743-2845
Country	:	US
Telephone Number	:	631-421-4100
Fax Number	:	631-421-5336

Provider Business Practice Location Address
First Line	:	110 E MAIN ST
Second Line	:	SUITE 3
City	:	HUNTINGTON
State	:	NY
Zip	:	11743-2845
Country	:	US
Telephone Number	:	631-421-4100
Fax Number	:	631-421-5336

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

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	07/08/2007

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