Provider Demographics
NPI:1114198504
Name:PROSPECT MEDICAL GROUP
Entity Type:Organization
Organization Name:PROSPECT MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-613-4442
Mailing Address - Street 1:555 PROSPECT PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-4266
Mailing Address - Country:US
Mailing Address - Phone:718-613-4442
Mailing Address - Fax:
Practice Address - Street 1:15 WOODCREST DR
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-3036
Practice Address - Country:US
Practice Address - Phone:718-613-4442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW01401Medicare PIN