Provider Demographics
NPI:1669613592
Name:LUSTIG, LILI ANN (DO)
Entity type:Individual
Prefix:
First Name:LILI
Middle Name:ANN
Last Name:LUSTIG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LILI
Other - Middle Name:ANN
Other - Last Name:FLAX-FRIEDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-3535
Mailing Address - Fax:239-343-4065
Practice Address - Street 1:42880 CRESCENT LOOP STE 110
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33982-5062
Practice Address - Country:US
Practice Address - Phone:239-343-3535
Practice Address - Fax:239-343-4065
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.010086207Q00000X
FLOS18030207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111233800Medicaid