Provider Demographics
NPI:1639198971
Name:LUNDGREN, SACHA (OD)
Entity Type:Individual
Prefix:
First Name:SACHA
Middle Name:
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 JOHN Q HAMMONS DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1941
Mailing Address - Country:US
Mailing Address - Phone:608-251-4156
Mailing Address - Fax:608-257-3842
Practice Address - Street 1:3051 CAHILL MAIN
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-7109
Practice Address - Country:US
Practice Address - Phone:608-661-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2855152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38613700Medicaid
WIU85401Medicare UPIN