Provider Demographics
NPI:1982799888
Name:LUNDEBERG, PATRICIA M (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:M
Last Name:LUNDEBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2303
Mailing Address - Country:US
Mailing Address - Phone:858-499-2777
Mailing Address - Fax:
Practice Address - Street 1:2001 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2303
Practice Address - Country:US
Practice Address - Phone:858-499-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56317207P00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G563170Medicaid
CAWG56317BMedicare ID - Type Unspecified
CA00G563170Medicaid