Healthcare Provider Details

I. General information

NPI: 1497854780
Provider Name (Legal Business Name): WILLIAM BRUCE LUNDEEN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N GEORGE MASON DR
ARLINGTON VA
22205-3610
US

IV. Provider business mailing address

12310 PINECREST RD SUITE 200
RESTON VA
20191-1653
US

V. Phone/Fax

Practice location:
  • Phone: 703-558-6284
  • Fax: 703-558-5512
Mailing address:
  • Phone: 703-860-1178
  • Fax: 703-860-1266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0101012571
License Number StateVA

VIII. Authorized Official

Name: WILLIAM B LUNDEEN
Title or Position: OWNER
Credential: MD
Phone: 703-766-8052