Provider Demographics
NPI:1811986375
Name:LUNDGREN, DANIEL JULIEN (OD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JULIEN
Last Name:LUNDGREN
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 1:4601 DALE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9718
Mailing Address - Country:US
Mailing Address - Phone:209-735-3150
Mailing Address - Fax:209-735-3155
Practice Address - Street 1:4601 DALE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9718
Practice Address - Country:US
Practice Address - Phone:209-735-3150
Practice Address - Fax:209-735-3155
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9435T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410047220OtherRAILROAD MEDICARE
CASD0094350Medicaid
SD0094350Medicare ID - Type Unspecified