Provider Demographics
NPI:1013370535
Name:LUNDGREN, ZACHARY (OD)
Entity Type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:
Last Name:LUNDGREN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 SOUTHBROOK LN
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-2110
Mailing Address - Country:US
Mailing Address - Phone:218-371-7022
Mailing Address - Fax:
Practice Address - Street 1:1603 SOUTHBROOK LN
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-2110
Practice Address - Country:US
Practice Address - Phone:218-371-7022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-01
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3339152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist