Provider Demographics
NPI:1588946123
Name:LUNDAHL, GARY ROBERT (BS)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:ROBERT
Last Name:LUNDAHL
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1245 SAGEBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-9416
Mailing Address - Country:US
Mailing Address - Phone:585-216-9991
Mailing Address - Fax:
Practice Address - Street 1:4148 MILLER ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:NY
Practice Address - Zip Code:14589-9713
Practice Address - Country:US
Practice Address - Phone:315-589-9668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY020455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist