Healthcare Provider Details

I. General information

NPI: 1518511443
Provider Name (Legal Business Name): ELIJAH THOMAS WOLF LUSTIG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 E 31ST ST
OAKLAND CA
94602-1018
US

IV. Provider business mailing address

1411 E 31ST ST
OAKLAND CA
94602-1018
US

V. Phone/Fax

Practice location:
  • Phone: 510-384-9737
  • Fax:
Mailing address:
  • Phone: 510-384-9737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number3293
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: