Provider Demographics
NPI:1790861656
Name:LUND, PAUL KENNETH (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:KENNETH
Last Name:LUND
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W GRANT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-5532
Mailing Address - Country:US
Mailing Address - Phone:520-792-0060
Mailing Address - Fax:520-624-6421
Practice Address - Street 1:201 W GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-5532
Practice Address - Country:US
Practice Address - Phone:520-792-0060
Practice Address - Fax:520-624-6421
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2089930Medicaid
CT2089930Medicaid