Provider Demographics
NPI:1861180259
Name:KRISTELLE LUSBY MD
Entity type:Organization
Organization Name:KRISTELLE LUSBY MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-586-3876
Mailing Address - Street 1:3425 S BASCOM AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-7300
Mailing Address - Country:US
Mailing Address - Phone:760-586-3876
Mailing Address - Fax:
Practice Address - Street 1:3425 S BASCOM AVE STE 100
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-7300
Practice Address - Country:US
Practice Address - Phone:408-396-1115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1932336278OtherNPPES