Provider Demographics
NPI:1184675415
Name:LUNDQUIST, FRED A (OD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:A
Last Name:LUNDQUIST
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 1:502 E. NEW HAVEN AVE.
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5427
Mailing Address - Country:US
Mailing Address - Phone:321-727-2020
Mailing Address - Fax:321-984-9547
Practice Address - Street 1:502 E. NEW HAVEN AVE.
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5427
Practice Address - Country:US
Practice Address - Phone:321-727-2020
Practice Address - Fax:321-984-9547
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC924152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2885280OtherAETNA HMO
FL4325330OtherAETNA PPO
FL620734100Medicaid
FL19983OtherBLUE CROSS / BLUE SHIELD
FL410047717OtherRAILROAD MEDICARE
FL528645500OtherCIGNA
FL2885280OtherAETNA HMO
FLU13358Medicare UPIN