Provider Demographics
NPI:1255378360
Name:LUNDY, EDWARD LESLIE (DO)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LESLIE
Last Name:LUNDY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:EDWARD
Other - Middle Name:LESLIE
Other - Last Name:LUNDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1017 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:NJ
Mailing Address - Zip Code:08030-1847
Mailing Address - Country:US
Mailing Address - Phone:856-456-1042
Mailing Address - Fax:856-456-8830
Practice Address - Street 1:1017 MARKET ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:NJ
Practice Address - Zip Code:08030-1847
Practice Address - Country:US
Practice Address - Phone:856-456-1042
Practice Address - Fax:856-456-8830
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB35070207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ146961Medicare PIN