Provider Demographics
NPI:1518947324
Name:LUSTGARTEN, MOISES (MD)
Entity Type:Individual
Prefix:DR
First Name:MOISES
Middle Name:
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:PO BOX 198054
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8054
Mailing Address - Country:US
Mailing Address - Phone:786-596-3876
Mailing Address - Fax:
Practice Address - Street 1:8950 N KENDALL DR STE 410W
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2127
Practice Address - Country:US
Practice Address - Phone:786-596-3876
Practice Address - Fax:786-533-9989
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76936207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL58934OtherBCBS
FL262047200Medicaid
FL58934OtherBCBS
FL58934XMedicare ID - Type Unspecified
FL262047200Medicaid
FL58934ZMedicare ID - Type Unspecified