Provider Demographics
NPI:1225009301
Name:LUSTBERG, ALEXANDER MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:MICHAEL
Last Name:LUSTBERG
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 1:500 DOYLE PARK DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 DOYLE PARK DR
Practice Address - Street 2:SUITE G04
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4558
Practice Address - Country:US
Practice Address - Phone:707-303-8349
Practice Address - Fax:707-303-2694
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA-86284207RG0100X
CAA86284207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A862840Medicaid
CA00A862840Medicaid
H69240Medicare UPIN
CA00A862840Medicaid
CABS656YMedicare PIN
CA00A862841Medicare PIN