Healthcare Provider Details

I. General information

NPI: 1376525501
Provider Name (Legal Business Name): MICHAEL EMORY LUSTGARTEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

834 E OCEAN BLVD
STUART FL
34994-2428
US

IV. Provider business mailing address

834 E OCEAN BLVD
STUART FL
34994-2428
US

V. Phone/Fax

Practice location:
  • Phone: 772-286-2950
  • Fax: 772-286-2339
Mailing address:
  • Phone: 772-286-2950
  • Fax: 772-286-2339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME0036091
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: