Provider Demographics
NPI:1558344119
Name:LUSTBADER, STEVEN S (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:S
Last Name:LUSTBADER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:STEVE
Other - Middle Name:
Other - Last Name:LUSTBADER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1040 DON DIEGO AVE
Mailing Address - Street 2:#14
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3600
Mailing Address - Country:US
Mailing Address - Phone:505-984-0602
Mailing Address - Fax:
Practice Address - Street 1:1040 DON DIEGO AVE
Practice Address - Street 2:#14
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3600
Practice Address - Country:US
Practice Address - Phone:505-984-0602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM78-562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM31047Medicaid
NM31047Medicaid
C97941Medicare UPIN