Provider Demographics
NPI:1265426621
Name:LUNDBERG, MAX S (MD)
Entity type:Individual
Prefix:DR
First Name:MAX
Middle Name:S
Last Name:LUNDBERG
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 1:11333 S 1000 E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-5429
Mailing Address - Country:US
Mailing Address - Phone:801-571-4100
Mailing Address - Fax:
Practice Address - Street 1:11333 S 1000 E
Practice Address - Street 2:SUITE 100
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094
Practice Address - Country:US
Practice Address - Phone:801-571-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1731351205207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT110033926OtherRAILROAD MEDICARE