Provider Demographics
NPI:1821358409
Name:LUSTGARTEN, JACQUELINE S (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:S
Last Name:LUSTGARTEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W 89TH ST
Mailing Address - Street 2:APT 2-M
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-1932
Mailing Address - Country:US
Mailing Address - Phone:201-926-9267
Mailing Address - Fax:
Practice Address - Street 1:100 W 89TH ST
Practice Address - Street 2:APT 2-M
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-1932
Practice Address - Country:US
Practice Address - Phone:201-926-9267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144616207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY144616OtherMEDICAL LICENSE