Provider Demographics
NPI:1639111065
Name:LUSTBERG, MARYAM BEHESHTI (MD)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:BEHESHTI
Last Name:LUSTBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARYAM
Other - Middle Name:
Other - Last Name:BEHESHTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-6529
Mailing Address - Fax:
Practice Address - Street 1:460 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-293-6529
Practice Address - Fax:614-293-9469
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.090303207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3093496Medicaid
OH3093496Medicaid