Provider Demographics
NPI:1982906483
Name:LUST, COURTNEY BRIAN (IDC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:BRIAN
Last Name:LUST
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 LION LN
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:NC
Mailing Address - Zip Code:28326-6277
Mailing Address - Country:US
Mailing Address - Phone:910-396-4240
Mailing Address - Fax:
Practice Address - Street 1:2D RECONNAISSANCE BN, BLDNG A-71
Practice Address - Street 2:PSC BOX 20138
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0138
Practice Address - Country:US
Practice Address - Phone:910-440-7719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman