Provider Demographics
NPI:1457300964
Name:LUNDER, ELISSA J (MD)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:J
Last Name:LUNDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:
Other - Last Name:LUNDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:65 WALNUT ST
Mailing Address - Street 2:STE 480
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-2118
Mailing Address - Country:US
Mailing Address - Phone:781-431-7733
Mailing Address - Fax:781-235-2665
Practice Address - Street 1:65 WALNUT ST
Practice Address - Street 2:STE 480
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-2118
Practice Address - Country:US
Practice Address - Phone:781-431-7733
Practice Address - Fax:781-235-2665
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208650207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ24423OtherBCBS
H46250Medicare UPIN
MAJ24423OtherBCBS