Provider Demographics
NPI:1699778787
Name:LUNDAK, BRUCE E (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:E
Last Name:LUNDAK
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 1:2315 E HARMONY RD STE 140
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-8620
Mailing Address - Country:US
Mailing Address - Phone:970-484-6700
Mailing Address - Fax:970-484-5723
Practice Address - Street 1:2315 E HARMONY RD STE 140
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-8620
Practice Address - Country:US
Practice Address - Phone:970-484-6700
Practice Address - Fax:970-484-5723
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20742208800000X
CODR.0070126208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE098396Medicare ID - Type Unspecified
NEG95587Medicare UPIN