Provider Demographics
NPI:1306841226
Name:LUNDERGAN, MAUREEN K (MD)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:K
Last Name:LUNDERGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5800
Mailing Address - Country:US
Mailing Address - Phone:716-632-3545
Mailing Address - Fax:716-632-6368
Practice Address - Street 1:6333 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5800
Practice Address - Country:US
Practice Address - Phone:716-632-3545
Practice Address - Fax:716-632-6368
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2013-08-13
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
UT1650381205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C63673Medicare UPIN