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General NPI Number Information
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NPI Number | 1942414081
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Entity Type | Organization
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Legal Business Name | TOWN AND COUNTRY PEDIATRICS AND FAMILY MEDICINE, P.C.
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Dates
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Enumeration Date | 05/09/2007
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Last Update Date | 12/12/2012
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Provider Practice Location Address
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Address Line | 380 MAIN STREET
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City | WATERTOWN
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State | CT
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Zip | 06795
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Country | US
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Telephone | 860-274-8891
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Fax | 860-274-8895
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Provider Business Mailing Address
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Address Line | 380 MAIN STREET
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City | WATERTOWN
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State | CT
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Zip | 06795
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Country | US
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Telephone | 860-274-8891
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Fax | 860-274-8895
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JACQUELINE O LUSTIG
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Credential | D.O.
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Telephone | 860-274-8891
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 041948
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 001457
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 035903
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License Number State | CT
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