Provider Demographics
NPI:1750336152
Name:LUNDIN, BRUCE (OD LLC)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:LUNDIN
Suffix:
Gender:M
Credentials:OD LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-3266
Mailing Address - Country:US
Mailing Address - Phone:360-406-2034
Mailing Address - Fax:
Practice Address - Street 1:955 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3266
Practice Address - Country:US
Practice Address - Phone:360-406-2034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00003612152W00000X
NVNV412152WC0802X
UT279166-9934152W00000X
NV726152W00000X
WA3612152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000009105OtherMEDICARE STORE #6 PTAN
UT999000797009Medicaid
UT000004473OtherMEDICARE STORE #04 PTAN
NV003116904Medicaid
NV004716904Medicaid
UTP00608618Medicare PIN
UT000004473OtherMEDICARE STORE #04 PTAN
NV004716904Medicaid
NV36755Medicare ID - Type Unspecified
NV003116904Medicaid
UT0618950003Medicare NSC