Provider Demographics
NPI:1346275567
Name:LUSTIK, BORIS (MD)
Entity Type:Individual
Prefix:DR
First Name:BORIS
Middle Name:
Last Name:LUSTIK
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 1:239 BOYLE ROAD
Mailing Address - Street 2:STE 7
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784
Mailing Address - Country:US
Mailing Address - Phone:631-698-0600
Mailing Address - Fax:631-698-2212
Practice Address - Street 1:239 BOYLE ROAD
Practice Address - Street 2:STE 7
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784
Practice Address - Country:US
Practice Address - Phone:631-698-0600
Practice Address - Fax:631-698-2212
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108221208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00656877Medicaid
NY00656877Medicaid
NY658741Medicare ID - Type Unspecified