Provider Demographics
NPI:1598100695
Name:LUNDY, MICHCAEL W (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:MICHCAEL
Middle Name:W
Last Name:LUNDY
Suffix:
Gender:M
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7303 S GAFFORD BLVD
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-2620
Mailing Address - Country:US
Mailing Address - Phone:918-893-2591
Mailing Address - Fax:
Practice Address - Street 1:7303 S GAFFORD BLVD
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-2620
Practice Address - Country:US
Practice Address - Phone:918-893-2591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1648133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered