MEDICARE: ANTHONY LUISTRO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MD432474	PA

General Provider Information

NPI Number	:	1396922076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY LUISTRO MD

Provider Business Mailing Address
First Line	:	2450 W. HUNTING PARK AVENUE
Second Line	:	2ND FLOOR, TPI-CBO
City	:	PHILADELPHIA
State	:	PA
Zip	:	19129-1302
Country	:	US
Telephone Number	:	215-926-9010
Fax Number	:	215-226-8285

Provider Business Practice Location Address
First Line	:	1300 W LEHIGH AVE STE A
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19132-2760
Country	:	US
Telephone Number	:	215-226-8800
Fax Number	:	215-226-8819

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2008
Last Update Date	:	03/16/2021

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