Provider Demographics
NPI:1134190887
Name:LUSTGARTEN, MARCIE (OD LLC)
Entity type:Individual
Prefix:DR
First Name:MARCIE
Middle Name:
Last Name:LUSTGARTEN
Suffix:
Gender:F
Credentials:OD LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:747 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3044
Practice Address - Country:US
Practice Address - Phone:203-245-1492
Practice Address - Fax:203-245-9002
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002226152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
061310883OtherAETNA
84069OtherAETNA
CT02226OtherVBA
061310883OtherCIGNA
061310883OtherUNICARE
117603OtherEYE CARE PLAN OF AMERICA
117603OtherCOLE VISION
906172OtherBLOCK VISION
P00125652OtherRAILROAD MEDICARE
061310883OtherTRICARE
061310883OtherGOLDEN RULE
061310883OtherHEALTH MANAGEMENT
610883OtherCONNECTICARE
P377925OtherOXFORD
061310883OtherUNITED HEALTHCARE
OVO248OtherHEALTHNET
CT004105575Medicaid
090002226CT01OtherBCBS OF CT
CT02226OtherVBA
CT004105575Medicaid