Provider Demographics
NPI:1699943589
Name:LUSTICK, MICHAEL JAY (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAY
Last Name:LUSTICK
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 1:30 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1802
Mailing Address - Country:US
Mailing Address - Phone:203-954-0543
Mailing Address - Fax:
Practice Address - Street 1:30 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1802
Practice Address - Country:US
Practice Address - Phone:203-954-0543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0236672084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry