Provider Demographics
NPI:1376525501
Name:LUSTGARTEN, MICHAEL EMORY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EMORY
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 1:834 E OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2428
Mailing Address - Country:US
Mailing Address - Phone:772-286-2950
Mailing Address - Fax:772-286-2339
Practice Address - Street 1:834 E OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2428
Practice Address - Country:US
Practice Address - Phone:772-286-2950
Practice Address - Fax:772-286-2339
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0036091208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065662300Medicaid
FL340000180OtherRAILROAD MEDICARE
FL065662300Medicaid
FL43073Medicare ID - Type Unspecified