Provider Demographics
NPI:1699759647
Name:LUNDSTROM, PAUL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:LUNDSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13359 ISLE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-2222
Mailing Address - Country:US
Mailing Address - Phone:218-454-7546
Mailing Address - Fax:
Practice Address - Street 1:13359 ISLE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-2222
Practice Address - Country:US
Practice Address - Phone:218-454-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45453207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN741720900Medicaid
MN741720900Medicaid
MN070000621Medicare ID - Type Unspecified