Provider Demographics
NPI:1316072598
Name:LUSTGARTEN, JACOB J (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:J
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 1:2041 GEORGIA AVE NW STE 3400
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20060-0001
Mailing Address - Country:US
Mailing Address - Phone:202-865-6679
Mailing Address - Fax:
Practice Address - Street 1:2041 GEORGIA AVE NW STE 4000
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20060-0001
Practice Address - Country:US
Practice Address - Phone:202-865-3785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012299142086S0102X
MDD00567002086S0129X
MDD567002086S0129X
DCMD326682086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
F89000Medicare UPIN
013840K92Medicare ID - Type Unspecified