Provider Demographics
NPI:1124246335
Name:LUSTIG, RYAN MATTHEW I (MD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MATTHEW
Last Name:LUSTIG
Suffix:I
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 1:4320 WORNALL RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-5941
Mailing Address - Country:US
Mailing Address - Phone:816-531-0552
Mailing Address - Fax:816-756-2503
Practice Address - Street 1:4320 WORNALL RD
Practice Address - Street 2:SUITE 208
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5941
Practice Address - Country:US
Practice Address - Phone:816-531-0552
Practice Address - Fax:816-756-2503
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009032079207RN0300X, 207R00000X
KS0434257207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01096578OtherRR MEDICARE