Provider Demographics
NPI:1740366368
Name:LUSTGARTEN, M.D.,F.A.C.S., GARY JAMES (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:JAMES
Last Name:LUSTGARTEN, M.D.,F.A.C.S.
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:JAMES
Other - Last Name:LUSTGARTEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:100 NW 170TH ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5513
Mailing Address - Country:US
Mailing Address - Phone:305-653-5155
Mailing Address - Fax:305-653-5513
Practice Address - Street 1:100 NW 170TH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33169-5513
Practice Address - Country:US
Practice Address - Phone:305-653-5155
Practice Address - Fax:305-653-5513
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0016186174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD65607Medicare UPIN
FL91134Medicare ID - Type UnspecifiedMEDICARE & BCBS OF FL #'S