Provider Demographics
NPI:1972708980
Name:LUNDQUIST, JOHN T (CPED)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:LUNDQUIST
Suffix:
Gender:M
Credentials:CPED
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2419 LEWISVILLE CLEMMONS RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8976
Mailing Address - Country:US
Mailing Address - Phone:336-712-4750
Mailing Address - Fax:336-712-1056
Practice Address - Street 1:2419 LEWISVILLE CLEMMONS RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8976
Practice Address - Country:US
Practice Address - Phone:336-712-4750
Practice Address - Fax:336-712-1056
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795236Medicaid