MEDICARE: DR. RANDY ROY LUNDELL D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	5807043-1204	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5807043-1204	OTHER	UT	MEDICAL LISC. #

General Provider Information

NPI Number	:	1336239888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDY ROY LUNDELL D.O.

Provider Business Mailing Address
First Line	:	468 S MAIN ST
Second Line	:
City	:	SPANISH FORK
State	:	UT
Zip	:	84660-2410
Country	:	US
Telephone Number	:	801-504-6117
Fax Number	:

Provider Business Practice Location Address
First Line	:	954 N 200 E STE 954
Second Line	:
City	:	SPANISH FORK
State	:	UT
Zip	:	84660-1247
Country	:	US
Telephone Number	:	801-504-6117
Fax Number	:	801-504-6328

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	09/29/2021

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