Provider Demographics
NPI:1386149912
Name:LUSK, CALEB MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:MATTHEW
Last Name:LUSK
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 1:593 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2521
Mailing Address - Country:US
Mailing Address - Phone:310-547-0202
Mailing Address - Fax:
Practice Address - Street 1:593 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2521
Practice Address - Country:US
Practice Address - Phone:310-547-0202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT69006207Q00000X
390200000X
CAA165385207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008056033Medicaid
CT008056168Medicaid
CT004217099Medicaid
CT008068298Medicaid
CT008039745Medicaid
CT008103790Medicaid