Provider Demographics
NPI:1841344678
Name:LUNDY, JONATHAN BERGENDAHL (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BERGENDAHL
Last Name:LUNDY
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 1:3698 CHAMBERS PASS
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-7766
Mailing Address - Country:US
Mailing Address - Phone:210-539-3219
Mailing Address - Fax:
Practice Address - Street 1:3698 CHAMBERS PASS
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-7766
Practice Address - Country:US
Practice Address - Phone:210-539-3219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND18872207XS0106X
GA054457208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAVAD 000Medicare UPIN