Provider Demographics
NPI:1952411191
Name:LUNDBLAD, EDWARD GORMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GORMAN
Last Name:LUNDBLAD
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 1:579 S LAREDO CIR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80017-2103
Mailing Address - Country:US
Mailing Address - Phone:303-671-8487
Mailing Address - Fax:303-671-5160
Practice Address - Street 1:579 S LAREDO CIR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80017-2103
Practice Address - Country:US
Practice Address - Phone:303-671-8487
Practice Address - Fax:303-671-5160
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25239174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01252394Medicaid
$$$$$$$$$OtherSOCIAL SECURITY NUMBER
CO01252394Medicaid