Provider Demographics
NPI:1063419117
Name:LUSTIG, ERIC STEVEN (DPM)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:STEVEN
Last Name:LUSTIG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6836 ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-2411
Mailing Address - Country:US
Mailing Address - Phone:214-471-0433
Mailing Address - Fax:215-471-0430
Practice Address - Street 1:4715 PINE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1831
Practice Address - Country:US
Practice Address - Phone:215-471-0433
Practice Address - Fax:215-471-0430
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002614L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PALU1436109OtherPA. BLUE SHIELD
PALU1436109OtherPA. BLUE SHIELD
PAT72709Medicare UPIN