Provider Demographics
NPI:1295949501
Name:LUSTER, MARCLAND LESLEY (PT)
Entity type:Individual
Prefix:
First Name:MARCLAND
Middle Name:LESLEY
Last Name:LUSTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 NE 14TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-1206
Mailing Address - Country:US
Mailing Address - Phone:405-740-7784
Mailing Address - Fax:405-319-9374
Practice Address - Street 1:702 NE 37TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-7210
Practice Address - Country:US
Practice Address - Phone:405-525-3024
Practice Address - Fax:405-525-3027
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT2179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist