Healthcare Provider Details

I. General information

NPI: 1275732075
Provider Name (Legal Business Name): ALSTON C LUNDGREN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 SAINT MICHAELS DR STE 801
SANTA FE NM
87505-7619
US

IV. Provider business mailing address

460 SAINT MICHAELS DR STE 801
SANTA FE NM
87505-7619
US

V. Phone/Fax

Practice location:
  • Phone: 505-986-0910
  • Fax: 505-986-0904
Mailing address:
  • Phone: 505-986-0910
  • Fax: 505-986-0904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number98-323
License Number StateNM

VIII. Authorized Official

Name: DR. ALSTON CLEMENS LUNDGREN
Title or Position: PRESIDENT
Credential: MD
Phone: 505-986-0910