Provider Demographics
NPI:1194819144
Name:LUSTGARTEN, MAURICE VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:VICTOR
Last Name:LUSTGARTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 100TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004
Mailing Address - Country:US
Mailing Address - Phone:425-454-3135
Mailing Address - Fax:425-451-8662
Practice Address - Street 1:27 100TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004
Practice Address - Country:US
Practice Address - Phone:425-454-3135
Practice Address - Fax:425-451-8662
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000116712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1523604Medicaid
WA1523604Medicaid