Healthcare Provider Details

I. General information

NPI: 1639111065
Provider Name (Legal Business Name): MARYAM BEHESHTI LUSTBERG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARYAM BEHESHTI M.D.

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 W 10TH AVE
COLUMBUS OH
43210-1240
US

IV. Provider business mailing address

700 ACKERMAN RD STE 2120
COLUMBUS OH
43202-1559
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-6529
  • Fax: 614-293-9469
Mailing address:
  • Phone: 614-293-6529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number35.090303
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: