Healthcare Provider Details

I. General information

NPI: 1962794982
Provider Name (Legal Business Name): ADAM CRAIG LUSTIG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

DEPT OF RADIOLOGY # 7510 2107 OLD CLINIC CLB
CHAPEL HILL NC
27599-0001
US

V. Phone/Fax

Practice location:
  • Phone: 757-466-0089
  • Fax:
Mailing address:
  • Phone: 804-828-3524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101252627
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number0101252627
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: