Healthcare Provider Details

I. General information

NPI: 1114507522
Provider Name (Legal Business Name): JEROLD LUNDGREN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

265 LORIMER ST APT 232
BROOKLYN NY
11206-3663
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-4501
  • Fax:
Mailing address:
  • Phone: 585-756-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number322983
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: