Provider Demographics
NPI:1316198922
Name:PROSPECT MEDICAL OFFICE, LLC
Entity Type:Organization
Organization Name:PROSPECT MEDICAL OFFICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BENNETT
Authorized Official - Middle Name:P
Authorized Official - Last Name:LEIFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-444-4526
Mailing Address - Street 1:301 GODWIN AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07432-1544
Mailing Address - Country:US
Mailing Address - Phone:201-444-4526
Mailing Address - Fax:201-689-0638
Practice Address - Street 1:301 GODWIN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07432-1544
Practice Address - Country:US
Practice Address - Phone:201-444-4526
Practice Address - Fax:201-689-0638
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROSPECT MEDICAL OFFICE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ613777Medicare PIN