Provider Demographics
NPI:1477551067
Name:LUSTY, DEBRA A (DO)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:LUSTY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:451 HIDDEN MEADOWS DR
Mailing Address - Street 2:SUITE
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-9812
Mailing Address - Country:US
Mailing Address - Phone:517-437-0010
Mailing Address - Fax:517-437-0319
Practice Address - Street 1:451 HIDDEN MEADOWS DR
Practice Address - Street 2:SUITE
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-9812
Practice Address - Country:US
Practice Address - Phone:517-437-0010
Practice Address - Fax:517-437-0319
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2014-04-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101009970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102058OtherGLHP
MI080044812OtherMEDICARE
MI0120047OtherPHP
MI2935050Medicaid
MIP89540OtherBCN
MI0153000045OtherBCBS
MI102058OtherGLHP
MI2935050Medicaid