Provider Demographics
NPI:1609956556
Name:PROSPECT MEDICAL OFFICE, LLC
Entity Type:Organization
Organization Name:PROSPECT MEDICAL OFFICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TEREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-444-4530
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJPR613777Medicare ID - Type UnspecifiedGROUP