Healthcare Provider Details

I. General information

NPI: 1255378360
Provider Name (Legal Business Name): EDWARD LESLIE LUNDY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: EDWARD LESLIE LUNDY DO

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 MARKET ST
GLOUCESTER NJ
08030-1847
US

IV. Provider business mailing address

1017 MARKET ST
GLOUCESTER NJ
08030-1847
US

V. Phone/Fax

Practice location:
  • Phone: 856-456-1042
  • Fax: 856-456-8830
Mailing address:
  • Phone: 856-456-1042
  • Fax: 856-456-8830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMB35070
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: