Basic Information
| Provider Information | |||||||||
| NPI: | 1396922076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUISTRO | ||||||||
| FirstName: | ANTHONY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 W. HUNTING PARK AVENUE | ||||||||
| Address2: | 2ND FLOOR, TPI-CBO | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159269010 | ||||||||
| FaxNumber: | 2152268285 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 W LEHIGH AVE STE A | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191322760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152268800 | ||||||||
| FaxNumber: | 2152268819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2008 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD432474 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.