Provider Demographics
NPI:1982688891
Name:LUNDQUIST, COLE DAVID (MD)
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:DAVID
Last Name:LUNDQUIST
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 1:7447 W. TALCOTT AVE
Mailing Address - Street 2:SUITE 321
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631
Mailing Address - Country:US
Mailing Address - Phone:773-774-7122
Mailing Address - Fax:773-631-7642
Practice Address - Street 1:1875 W DEMPSTER ST
Practice Address - Street 2:STE 660
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1186
Practice Address - Country:US
Practice Address - Phone:847-698-1210
Practice Address - Fax:847-698-0475
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056878207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056878Medicaid
657310Medicare ID - Type Unspecified
IL036056878Medicaid