Provider Demographics
NPI:1649266149
Name:LINDSTROM, PAUL M (OD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:LINDSTROM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:773 SLATE LEDGE RD
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:NH
Mailing Address - Zip Code:03561-3432
Mailing Address - Country:US
Mailing Address - Phone:603-444-5989
Mailing Address - Fax:
Practice Address - Street 1:1290 HOSPITAL DR
Practice Address - Street 2:SUITE 5
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9239
Practice Address - Country:US
Practice Address - Phone:802-748-8126
Practice Address - Fax:802-748-2208
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0300000266152W00000X
NH0622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN1122Medicaid
NH30008906Medicaid
VTVN1122OtherMEDICARE PTAN
NHRE5917OtherMEDICARE PTAN
NHRE5917Medicare ID - Type Unspecified
NHRE5917OtherMEDICARE PTAN
U55645Medicare UPIN