Provider Demographics
NPI:1619901048
Name:LUNGREN, MAX A (MD)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:A
Last Name:LUNGREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1605 MARTIN SPRINGS DR
Practice Address - Street 2:STE 320
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2931
Practice Address - Country:US
Practice Address - Phone:573-458-6359
Practice Address - Fax:573-458-6826
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA28735207V00000X
MO2011021431207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2083642Medicaid
MO1619901048Medicaid
MO43-1560263OtherTRICARE
MO1619901048Medicaid
IA2083642Medicaid