Provider Demographics
NPI:1902828924
Name:LUNDBERG, GINA P (MD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:P
Last Name:LUNDBERG
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 1:1838 AMERICAN WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6611
Mailing Address - Country:US
Mailing Address - Phone:770-995-7622
Mailing Address - Fax:770-995-7854
Practice Address - Street 1:137 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 1200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4945
Practice Address - Country:US
Practice Address - Phone:678-843-9601
Practice Address - Fax:678-843-9650
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032458207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00604172AMedicaid
GA000604172PMedicaid
GA00604172OMedicaid
GA000604172NMedicaid
GA00604172AMedicaid
GA000604172NMedicaid
GA00604172OMedicaid