Provider Demographics
NPI:1578736120
Name:DR. LUSTGARTEN
Entity Type:Organization
Organization Name:DR. LUSTGARTEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:LUSTGARTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-245-8217
Mailing Address - Street 1:15 MEIGS AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-3057
Mailing Address - Country:US
Mailing Address - Phone:203-245-8217
Mailing Address - Fax:
Practice Address - Street 1:15 MEIGS AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3057
Practice Address - Country:US
Practice Address - Phone:203-245-8217
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT476111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004095099Medicaid
CT350000366Medicare PIN