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General NPI Number Information
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NPI Number | 1700043643
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Entity Type | Individual
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Provider Name | BRYAN ELLIOT LUSK M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/19/2008
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Last Update Date | 04/07/2010
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Provider Practice Location Address
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Address Line | 451 ASHLEY RIDGE BLVD
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City | SHREVEPORT
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State | LA
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Zip | 71106-7229
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Country | US
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Telephone | 318-222-5555
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Fax | 318-222-6414
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Provider Business Mailing Address
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Address Line | 451 ASHLEY RIDGE BLVD
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City | SHREVEPORT
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State | LA
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Zip | 71106-7229
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Country | US
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Telephone | 318-222-5555
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Fax | 318-222-6414
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 203516
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 62138
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License Number State | GA
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