Provider Demographics
NPI:1063492734
Name:LUNDSTROM, GARY KARL (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:KARL
Last Name:LUNDSTROM
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 1:2 WAKE ROBIN RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-4241
Mailing Address - Country:US
Mailing Address - Phone:401-333-8090
Mailing Address - Fax:
Practice Address - Street 1:2 WAKE ROBIN RD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-4241
Practice Address - Country:US
Practice Address - Phone:401-333-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI071712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D87397Medicare UPIN