MEDICARE: JESSICA LYNN LASTIG 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	2085B0100X	Body Imaging Physician	177033	NY
2	2085R0202X	Diagnostic Radiology Physician	177033	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902868292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LYNN LASTIG M.D.

Provider Business Mailing Address
First Line	:	935 NORTHERN BLVD
Second Line	:	SUITE 200
City	:	GREAT NECK
State	:	NY
Zip	:	11021-5309
Country	:	US
Telephone Number	:	516-829-4414
Fax Number	:	516-829-5286

Provider Business Practice Location Address
First Line	:	935 NORTHERN BLVD
Second Line	:	SUITE 200
City	:	GREAT NECK
State	:	NY
Zip	:	11021-5309
Country	:	US
Telephone Number	:	516-829-4414
Fax Number	:	516-829-5286

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

Provider Enumeration Date	:	04/04/2006
Last Update Date	:	07/02/2008

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