Provider Demographics
NPI:1699875583
Name:NORLUND, JOHN DERXSON (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DERXSON
Last Name:NORLUND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 ORCHARD PARK RD
Mailing Address - Street 2:A100
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-2646
Mailing Address - Country:US
Mailing Address - Phone:716-674-6800
Mailing Address - Fax:716-674-6804
Practice Address - Street 1:550 ORCHARD PARK RD
Practice Address - Street 2:A100
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-2646
Practice Address - Country:US
Practice Address - Phone:716-674-6800
Practice Address - Fax:716-674-6804
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139408174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01030735Medicaid
NYB55407Medicare UPIN
NYRB0258Medicare ID - Type Unspecified