Provider Demographics
NPI:1225011315
Name:LUNDGREN, SCOTT B (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:B
Last Name:LUNDGREN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13215 N 7TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-5300
Mailing Address - Country:US
Mailing Address - Phone:602-805-5041
Mailing Address - Fax:602-805-5013
Practice Address - Street 1:13215 N 7TH ST STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-5300
Practice Address - Country:US
Practice Address - Phone:602-805-5041
Practice Address - Fax:602-805-5013
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36786-021207L00000X
AZ007093207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ402744Medicaid
050081894OtherRAIL ROAD MEDICARE
WI30066800Medicaid
WI0011-32300Medicare ID - Type UnspecifiedPROVIDER NUMBER
WI0001-32415Medicare ID - Type UnspecifiedPROVIDER NUMBER