Provider Demographics
NPI:1326158866
Name:LUSTIG, CHAVA (DO)
Entity Type:Individual
Prefix:
First Name:CHAVA
Middle Name:
Last Name:LUSTIG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LN
Mailing Address - Street 2:STE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7176
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:290 INDIAN TRCE
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-4509
Practice Address - Country:US
Practice Address - Phone:954-908-3604
Practice Address - Fax:954-903-4075
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8758207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI33404Medicare UPIN
FL09015ZMedicare PIN