Provider Demographics
NPI:1093896367
Name:LUSTIG, DAVID MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:LUSTIG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13933 17TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33525-4604
Mailing Address - Country:US
Mailing Address - Phone:352-437-4505
Mailing Address - Fax:352-437-4709
Practice Address - Street 1:13933 17TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-4604
Practice Address - Country:US
Practice Address - Phone:352-437-4505
Practice Address - Fax:352-437-4709
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 128530208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA340018922OtherRAILROAD MEDICARE
VA434494OtherANTHEM
VA542025035OtherTRICARE
VA7503962OtherVIRGINIA PREMIER
VI0380470OtherCIGNA
VA3433588OtherAETNA
VA2127380OtherMDIPA
VA007503962Medicaid
VA3433588OtherAETNA
VAB08975Medicare UPIN