Provider Demographics
NPI:1417148503
Name:JACK LUND DO PA
Entity Type:Organization
Organization Name:JACK LUND DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUND
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-843-8688
Mailing Address - Street 1:6545 RIDGE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-6865
Mailing Address - Country:US
Mailing Address - Phone:727-843-8688
Mailing Address - Fax:727-841-8300
Practice Address - Street 1:6545 RIDGE RD STE 1
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-6865
Practice Address - Country:US
Practice Address - Phone:727-843-8688
Practice Address - Fax:727-841-8300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 0001626208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4669Medicare PIN