=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669585691
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EUGENE JAY LUSTGARTEN DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2006
-----------------------------------------------------
Last Update Date | 10/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3075 W OAKLAND PARK BLVD STE 101
-----------------------------------------------------
City | OAKLAND PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33311-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-677-8484
-----------------------------------------------------
Fax | 954-677-8966
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3075 W OAKLAND PARK BLVD STE 101
-----------------------------------------------------
City | OAKLAND PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33311-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-677-8484
-----------------------------------------------------
Fax | 954-677-8966
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 476
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH4616
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X003820-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------