MEDICARE: STEVEN S LUSTBADER M.D.

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	2084P0800X	Psychiatry Physician	78-56	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558344119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEVEN S LUSTBADER M.D.

Provider Business Mailing Address
First Line	:	1040 DON DIEGO AVE
Second Line	:	#14
City	:	SANTA FE
State	:	NM
Zip	:	87505-3600
Country	:	US
Telephone Number	:	505-984-0602
Fax Number	:

Provider Business Practice Location Address
First Line	:	1040 DON DIEGO AVE
Second Line	:	#14
City	:	SANTA FE
State	:	NM
Zip	:	87505-3600
Country	:	US
Telephone Number	:	505-984-0602
Fax Number	:

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

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	05/23/2012

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