Provider Demographics
NPI:1679815559
Name:PROSPER PEDIATRICS
Entity Type:Organization
Organization Name:PROSPER PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MAGALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PROSPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-421-9176
Mailing Address - Street 1:1825 FOSTER AVE
Mailing Address - Street 2:SUITE 1JJ
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-1834
Mailing Address - Country:US
Mailing Address - Phone:718-421-9176
Mailing Address - Fax:718-421-1539
Practice Address - Street 1:1825 FOSTER AVE
Practice Address - Street 2:SUITE 1JJ
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-1834
Practice Address - Country:US
Practice Address - Phone:718-421-9176
Practice Address - Fax:718-421-1539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189546173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01605476Medicaid