Provider Demographics
NPI:1770518789
Name:LUNDBERG, SCOTT RYAN (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:RYAN
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 1:14445 OLIVE VIEW DRIVE
Mailing Address - Street 2:ROOM 2B182 MEDICINE
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342
Mailing Address - Country:US
Mailing Address - Phone:818-364-3205
Mailing Address - Fax:818-364-3044
Practice Address - Street 1:14445 OLIVE VIEW DRIVE
Practice Address - Street 2:ROOM 2B182 MEDICINE
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342
Practice Address - Country:US
Practice Address - Phone:818-364-3205
Practice Address - Fax:818-364-3044
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73074207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I08766Medicare UPIN