Basic Information
| Provider Information | |||||||||
| NPI: | 1245252600 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUSTIG | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3201 MIDDLE DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472034427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123728281 | ||||||||
| FaxNumber: | 8123724525 | ||||||||
| Practice Location | |||||||||
| Address1: | 3201 MIDDLE DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472034427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123728281 | ||||||||
| FaxNumber: | 8123724525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 04/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01028641A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080084365 | 01 | MEDICARE RR | OTHER | 000000991451 | 01 | IN | ANTHEM PIN | OTHER | 100052010 | 05 | IN | MEDICAID |