Basic Information
Provider Information | |||||||||
NPI: | 1144450503 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LUSTIG | ||||||||
FirstName: | DEBRA | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DOUGHERTY | ||||||||
OtherFirstName: | DEBRA | ||||||||
OtherMiddleName: | K | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 781076 | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482781076 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3175284800 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8778 MADISON AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462277204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178889669 | ||||||||
FaxNumber: | 3178857966 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2009 | ||||||||
LastUpdateDate: | 03/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71002966A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 200951000 | 05 | IN |   | MEDICAID |