Provider Demographics
NPI:1134183130
Name:SUSTARSIC, DAVID L (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:SUSTARSIC
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 1:511 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7326
Mailing Address - Country:US
Mailing Address - Phone:352-728-6808
Mailing Address - Fax:352-728-1743
Practice Address - Street 1:511 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7326
Practice Address - Country:US
Practice Address - Phone:352-728-6808
Practice Address - Fax:352-728-1743
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43704208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35206OtherBLUE CROSS BLUE SHIELD
FL040867100Medicaid
FL35206OtherBLUE CROSS BLUE SHIELD
FLK0474Medicare ID - Type Unspecified