Provider Demographics
NPI:1760490635
Name:LUNDGREN, EDWARD A (PT)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:A
Last Name:LUNDGREN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 W PALMETTO PARK RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-3809
Mailing Address - Country:US
Mailing Address - Phone:561-338-8851
Mailing Address - Fax:561-391-0490
Practice Address - Street 1:199 W PALMETTO PARK RD
Practice Address - Street 2:SUITE 7
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-3809
Practice Address - Country:US
Practice Address - Phone:561-338-8851
Practice Address - Fax:561-391-0490
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT798225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
106826Medicare ID - Type Unspecified