Provider Demographics
NPI:1871694679
Name:LUNDERMAN, JACK C JR (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:C
Last Name:LUNDERMAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7901 SCHATZ POINTE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3856
Mailing Address - Country:US
Mailing Address - Phone:937-438-9841
Mailing Address - Fax:937-438-9851
Practice Address - Street 1:7901 SCHATZ POINTE DR
Practice Address - Street 2:SUITE A
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-3856
Practice Address - Country:US
Practice Address - Phone:937-438-9841
Practice Address - Fax:937-438-9851
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0524302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0720689Medicaid
0626271Medicare PIN
OH0720689Medicaid