Provider Demographics
NPI:1619930047
Name:LUNDSTROM, TREVOR ALDEN (MD)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:ALDEN
Last Name:LUNDSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4517 SOUTHLAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-3280
Mailing Address - Country:US
Mailing Address - Phone:205-985-4111
Mailing Address - Fax:205-985-4326
Practice Address - Street 1:4517 SOUTHLAKE PKWY
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-3280
Practice Address - Country:US
Practice Address - Phone:205-985-4111
Practice Address - Fax:205-985-4326
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL237922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51529306OtherBLUE CROSS BLUE SHIELD
AL51527709OtherBLUE CROSS/BLUE SHIELD
AL051529306Medicaid
AL51527723OtherBLUE CROSS/BLUE SHIELD
AL009998935Medicaid
AL51529306Medicare ID - Type Unspecified