Provider Demographics
NPI:1174554240
Name:LUNDERGAN, FAYE SUSAN (MD)
Entity type:Individual
Prefix:MRS
First Name:FAYE
Middle Name:SUSAN
Last Name:LUNDERGAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1456 PROFESSIONAL DR
Mailing Address - Street 2:STE 405
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:707-769-7500
Mailing Address - Fax:707-769-7570
Practice Address - Street 1:1456 PROFESSIONAL DR STE 405
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:707-769-7500
Practice Address - Fax:707-769-7570
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76943208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A769430Medicare ID - Type Unspecified