Basic Information
| Provider Information | |||||||||
| NPI: | 1538144167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUSTIG | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 5TH AVE N | ||||||||
| Address2: | STE 302 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278212388 | ||||||||
| FaxNumber: | 7278216887 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 5TH AVE N | ||||||||
| Address2: | STE 302 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278212388 | ||||||||
| FaxNumber: | 7278216887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 10/26/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | ME0056761 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | P00082790 | 01 | RR RETIREMENT MEDICARE | OTHER |