Provider Demographics
NPI:1801815956
Name:LUNDEEN, JOHN GILBERT (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:GILBERT
Last Name:LUNDEEN
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:PO BOX 1108
Mailing Address - Street 2:ATTN BARB SIMMONS
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-1108
Mailing Address - Country:US
Mailing Address - Phone:734-677-7400
Mailing Address - Fax:734-677-7407
Practice Address - Street 1:406 ELM ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:MI
Practice Address - Zip Code:48811
Practice Address - Country:US
Practice Address - Phone:989-584-3971
Practice Address - Fax:989-584-2161
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010239382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICA3518OtherMEDICARE RR GROUP PIN
MI4085919Medicaid
MI0F36125Medicare PIN
MI4085919Medicaid
MI0D46002021Medicare ID - Type Unspecified
MI0D46002Medicare PIN