1972708980 NPI number — JOHN T LUNDQUIST C.PED.

Table of content: JOHN T LUNDQUIST C.PED. (NPI 1972708980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972708980 NPI number — JOHN T LUNDQUIST C.PED.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUNDQUIST
Provider First Name:
JOHN
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
C.PED.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972708980
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2419 LEWISVILLE CLEMMONS RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
CLEMMONS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27012-8976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-712-4750
Provider Business Mailing Address Fax Number:
336-712-1056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2419 LEWISVILLE CLEMMONS RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
CLEMMONS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27012-8976
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-712-4750
Provider Business Practice Location Address Fax Number:
336-712-1056
Provider Enumeration Date:
06/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7795236 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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