Provider Demographics
NPI:1710973565
Name:RUNDQUIST, CAROLYN (MD)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:
Last Name:RUNDQUIST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 CENTRE STREET
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130
Mailing Address - Country:US
Mailing Address - Phone:617-983-4103
Mailing Address - Fax:617-971-9521
Practice Address - Street 1:640 CENTRE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2555
Practice Address - Country:US
Practice Address - Phone:617-983-4103
Practice Address - Fax:617-971-9521
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87364208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F91905Medicare UPIN