Provider Demographics
NPI:1811982531
Name:LUSTBERG, THOMAS J (MD FACS)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:LUSTBERG
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:379 6TH AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8820
Mailing Address - Country:US
Mailing Address - Phone:941-782-4259
Mailing Address - Fax:941-782-4101
Practice Address - Street 1:379 6TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-8820
Practice Address - Country:US
Practice Address - Phone:941-782-4259
Practice Address - Fax:941-782-4101
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME858682084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8738ZMedicare ID - Type Unspecified
B93462Medicare UPIN