Healthcare Provider Details

I. General information

NPI: 1497761407
Provider Name (Legal Business Name): IAN J LUSTBADER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 E 55TH ST
NEW YORK NY
10022-3205
US

IV. Provider business mailing address

55 E 55TH ST
NEW YORK NY
10022-3205
US

V. Phone/Fax

Practice location:
  • Phone: 646-754-2000
  • Fax: 646-754-9690
Mailing address:
  • Phone: 646-754-2000
  • Fax: 646-754-9690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number154801
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number154801
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: