1184675415 NPI number — FRED A LUNDQUIST OD

Table of content: FRED A LUNDQUIST OD (NPI 1184675415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184675415 NPI number — FRED A LUNDQUIST OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUNDQUIST
Provider First Name:
FRED
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

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:
1184675415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
502 E. NEW HAVEN AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32901-5427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-727-2020
Provider Business Mailing Address Fax Number:
321-984-9547

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
502 E. NEW HAVEN AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-5427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-727-2020
Provider Business Practice Location Address Fax Number:
321-984-9547
Provider Enumeration Date:
05/12/2006

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: 152W00000X , with the licence number:  OPC924 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2885280 . This is a "AETNA HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 4325330 . This is a "AETNA PPO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 620734100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 19983 . This is a "BLUE CROSS / BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 410047717 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 528645500 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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