Provider Demographics
NPI:1932143419
Name:LUNDGREN, DANIEL JOHN (PT)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:JOHN
Last Name:LUNDGREN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 MOUNT CASTLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-4834
Mailing Address - Country:US
Mailing Address - Phone:336-534-0634
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:BLDG 3/I
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA225100000XOtherPHYSICAL THERAPIST