Provider Demographics
NPI:1871584458
Name:LUSTGARTEN, MARSHALL D (MD)
Entity type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:D
Last Name:LUSTGARTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 E THOMAS RD
Mailing Address - Street 2:STE. A-1245
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7710
Mailing Address - Country:US
Mailing Address - Phone:602-546-1207
Mailing Address - Fax:602-546-1264
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-546-1207
Practice Address - Fax:602-546-1264
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ63442085P0229X
AZ063442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Y6439Medicaid
AZ256281Medicaid
AZ256281Medicaid
WCFGD-03Medicare ID - Type Unspecified