Healthcare Provider Details

I. General information

NPI: 1336295930
Provider Name (Legal Business Name): INGRID SC LUNDGREN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST STE 200
BOISE ID
83712-6267
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7330
  • Fax:
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License NumberM11411
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: