Provider Demographics
NPI:1619267952
Name:LUNDBERG, PETER WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:WILLIAM
Last Name:LUNDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1111 MEDICAL CENTER BLVD STE S860
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3136
Mailing Address - Country:US
Mailing Address - Phone:504-349-6860
Mailing Address - Fax:504-349-6865
Practice Address - Street 1:1111 MEDICAL CENTER BLVD STE S860
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3136
Practice Address - Country:US
Practice Address - Phone:504-349-6860
Practice Address - Fax:504-349-6865
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA310253208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA103320820Medicaid