Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0200X | Radiology | 6455 | TX |
Y | 213ER0200X | Radiology | 6455 | TX |
NPI | 1356408694 |
---|---|
Provider Name | Dr. Kenneth Lustik |
First Address | Dallas, TX 75218-2764 |
Second Address | Dallas, TX 75218-2764 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2007 |
Last Update Date | 08/07/2007 |