Provider Demographics
NPI:1316196041
Name:LUNDQUIST, RYAN BENTON (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:BENTON
Last Name:LUNDQUIST
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 1:3660 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8005
Mailing Address - Country:US
Mailing Address - Phone:239-936-3292
Mailing Address - Fax:239-936-3099
Practice Address - Street 1:14551 HOPE CENTER LOOP STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4705
Practice Address - Country:US
Practice Address - Phone:239-936-2316
Practice Address - Fax:239-936-3099
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00543142085R0202X
FLME1208302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017169800Medicaid