Provider Demographics
NPI:1376819417
Name:LUND, ALEXANDER DAVIS (DO)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:DAVIS
Last Name:LUND
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 1:77 W FOREST AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1482
Mailing Address - Country:US
Mailing Address - Phone:928-773-2222
Mailing Address - Fax:928-773-2287
Practice Address - Street 1:77 W FOREST AVE STE 107
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-773-2222
Practice Address - Fax:928-773-2598
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007572207Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ397509Medicaid