Provider Demographics
NPI:1992797955
Name:LUNDGREN, PAUL H (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:H
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:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12181-0689
Mailing Address - Country:US
Mailing Address - Phone:518-268-5000
Mailing Address - Fax:
Practice Address - Street 1:1300 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-1628
Practice Address - Country:US
Practice Address - Phone:518-268-6406
Practice Address - Fax:518-268-6294
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156804207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00951648Medicaid
NY00951648Medicaid
NYB82771Medicare UPIN