1427101146 NPI number — DR. LAURA M LUNDGREN M.D.

Table of content: DR. LAURA M LUNDGREN M.D. (NPI 1427101146)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427101146 NPI number — DR. LAURA M LUNDGREN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUNDGREN
Provider First Name:
LAURA
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427101146
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 191
Provider Second Line Business Mailing Address:
PROVIDER ENROLLMENT
Provider Business Mailing Address City Name:
ROCKLAND
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19732-0191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-651-6212
Provider Business Mailing Address Fax Number:
302-651-4945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 CLEAVER FARM RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19709-1630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-633-6338
Provider Business Practice Location Address Fax Number:
302-651-4945
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  C1-000804. , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C1-0008043 . This is a "PROFESSIONAL LICENSE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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