Healthcare Provider Details

I. General information

NPI: 1336177336
Provider Name (Legal Business Name): TOBY LUSTIG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: EMIL T LUSTIG

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1822 SAN MIGUEL DRIVE
WALNUT CREEK CA
94596
US

IV. Provider business mailing address

1822 SAN MIGUEL DRIVE
WALNUT CREEK CA
94596
US

V. Phone/Fax

Practice location:
  • Phone: 925-945-3850
  • Fax: 925-934-0471
Mailing address:
  • Phone: 925-945-3850
  • Fax: 925-934-0471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG80520
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: