Healthcare Provider Details

I. General information

NPI: 1386061844
Provider Name (Legal Business Name): MARY LUNDGREN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2014
Last Update Date: 03/28/2022
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 E SPAULDING AVE
PUEBLO CO
81008-2209
US

IV. Provider business mailing address

3530 E SPAULDING AVE
PUEBLO CO
81008-2209
US

V. Phone/Fax

Practice location:
  • Phone: 719-296-9000
  • Fax: 719-296-9001
Mailing address:
  • Phone: 719-296-9000
  • Fax: 719-296-9001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number67638
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number73026-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: