Provider Demographics
NPI:1992791206
Name:LUNDGREN, ERIC C (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:C
Last Name:LUNDGREN
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 1:605 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1479
Mailing Address - Country:US
Mailing Address - Phone:814-371-8569
Mailing Address - Fax:814-371-8603
Practice Address - Street 1:605 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1479
Practice Address - Country:US
Practice Address - Phone:814-371-8569
Practice Address - Fax:814-371-8603
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041884E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012492680003Medicaid
PA020051707OtherRAILROAD MEDICARE
PA020051707OtherRAILROAD MEDICARE
PA020051707OtherRAILROAD MEDICARE