Provider Demographics
NPI:1346978467
Name:LUNDBERG, JOHN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LUNDBERG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 BROAD ST STE 203
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3006
Mailing Address - Country:US
Mailing Address - Phone:407-865-7153
Mailing Address - Fax:407-865-7159
Practice Address - Street 1:901 DOUGLAS AVE STE 105
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-2058
Practice Address - Country:US
Practice Address - Phone:407-865-7153
Practice Address - Fax:407-865-7159
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT38751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist