Provider Demographics
NPI:1578654661
Name:LUNDY, THERESA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:MARIE
Last Name:LUNDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 NE KENNETH FORD DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1042
Mailing Address - Country:US
Mailing Address - Phone:541-672-9596
Mailing Address - Fax:541-464-3519
Practice Address - Street 1:150 NE KENNETH FORD DR
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1042
Practice Address - Country:US
Practice Address - Phone:541-672-9596
Practice Address - Fax:541-464-3519
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13681207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR103163OtherMEDICARE PART B
OR168395Medicare Oscar/Certification
ORR103163OtherMEDICARE PART B
OR381846Medicare Oscar/Certification