Provider Demographics
NPI:1518923150
Name:LUSTBADER, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:LUSTBADER
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 1:701 FIFTH STREET
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009
Mailing Address - Country:US
Mailing Address - Phone:724-775-6500
Mailing Address - Fax:724-775-6755
Practice Address - Street 1:701 FIFTH STREET
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009
Practice Address - Country:US
Practice Address - Phone:724-775-6500
Practice Address - Fax:724-775-6755
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031897E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA251603474-00OtherBWC
PAB36620OtherHEALTH AMERICA UPIN
PA000000115067OtherANTHEM BC BS
PA251711755OtherHEALTH AMERICA
PA34002813OtherRAILROAD MEDICARE
PA251711755OtherUPMC
PA10296OtherMED PLUS INDIVIDUAL
PA105466OtherBLUE SHEILD PA
OH0794145Medicaid
PA983011-0004Medicaid
OH0949960Medicaid
PA1008649OtherGATEWAY INDIVIDUAL
PA34002813OtherRAILROAD MEDICARE
PA251603474-00OtherBWC
OH0949960Medicaid