Provider Demographics
NPI:1891741872
Name:LJUNGREN, WARREN R (MD)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:R
Last Name:LJUNGREN
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 1:111 HARBERT DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45440-5117
Mailing Address - Country:US
Mailing Address - Phone:937-208-7575
Mailing Address - Fax:937-208-7590
Practice Address - Street 1:111 HARBERT DR
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45440-5117
Practice Address - Country:US
Practice Address - Phone:937-208-7575
Practice Address - Fax:937-208-7590
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.052195207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0599820Medicaid
OH0623252Medicare PIN
OH0623253Medicare PIN
A83202Medicare UPIN