Basic Information
| Provider Information | |||||||||
| NPI: | 1134190887 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUSTGARTEN | ||||||||
| FirstName: | MARCIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 747 BOSTON POST RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064433044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032451492 | ||||||||
| FaxNumber: | 2032459002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 002226 | CT | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 061310883 | 01 | AETNA | OTHER | 84069 | 01 | AETNA | OTHER | CT02226 | 01 | VBA | OTHER | 061310883 | 01 | CIGNA | OTHER | 061310883 | 01 | UNICARE | OTHER | 117603 | 01 | EYE CARE PLAN OF AMERICA | OTHER | 117603 | 01 | COLE VISION | OTHER | 906172 | 01 | BLOCK VISION | OTHER | P00125652 | 01 | RAILROAD MEDICARE | OTHER | 061310883 | 01 | TRICARE | OTHER | 061310883 | 01 | GOLDEN RULE | OTHER | 061310883 | 01 | HEALTH MANAGEMENT | OTHER | 610883 | 01 | CONNECTICARE | OTHER | P377925 | 01 | OXFORD | OTHER | 061310883 | 01 | UNITED HEALTHCARE | OTHER | OVO248 | 01 | HEALTHNET | OTHER | 004105575 | 05 | CT | MEDICAID | 090002226CT01 | 01 | BCBS OF CT | OTHER |