Provider Demographics
NPI:1386061844
Name:LUNDGREN, MARY (DO)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 E SPAULDING AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2209
Mailing Address - Country:US
Mailing Address - Phone:719-296-9000
Mailing Address - Fax:719-296-9001
Practice Address - Street 1:3530 E SPAULDING AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2209
Practice Address - Country:US
Practice Address - Phone:719-296-9000
Practice Address - Fax:719-296-9001
Is Sole Proprietor?:No
Enumeration Date:2014-03-23
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73026-21207XS0117X
CO67638207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine