Provider Demographics
NPI:1376524579
Name:LUNDERGAN, CONOR F (MD)
Entity Type:Individual
Prefix:
First Name:CONOR
Middle Name:F
Last Name:LUNDERGAN
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 1:12070 OLD LINE CTR
Mailing Address - Street 2:STE 303
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602
Mailing Address - Country:US
Mailing Address - Phone:301-475-3240
Mailing Address - Fax:301-475-9740
Practice Address - Street 1:12070 OLD LINE CTR
Practice Address - Street 2:STE 303
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602
Practice Address - Country:US
Practice Address - Phone:301-475-3240
Practice Address - Fax:301-475-9740
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0034663207RC0000X
DCMD17986207RC0000X
NC29618207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD606188-03OtherBCBS
MDKP061952Medicare ID - Type Unspecified
MD606188-03OtherBCBS