Provider Demographics
NPI:1679671366
Name:LANTSBERG, IGOR A (MD)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:A
Last Name:LANTSBERG
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 1:4200 WARRENSVILLE CENTER RD
Mailing Address - Street 2:STE 344
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7051
Mailing Address - Country:US
Mailing Address - Phone:216-561-8844
Mailing Address - Fax:216-561-8894
Practice Address - Street 1:4200 WARRENSVILLE CENTER RD
Practice Address - Street 2:STE 344
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-7051
Practice Address - Country:US
Practice Address - Phone:216-561-8844
Practice Address - Fax:216-561-8894
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042712207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341264282026OtherCARESOURCE
OH0376454Medicaid
OH102353OtherKAISER
OH000000129201OtherANTHEM
OHR42712OtherSUMMACARE
OH110064729OtherRR MEDICARE
OH341264282OtherCHAMPUS/TRICARE
OH58931OtherQUALCHOICE
OHA77956Medicare UPIN
OH102353OtherKAISER