Healthcare Provider Details

I. General information

NPI: 1609808005
Provider Name (Legal Business Name): ALSTON C LUNDGREN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/09/2007
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 ST. MICHAEL'S DR. STE. 801
SANTA FE NM
87505
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:
Title or Position:
Credential:
Phone: