Provider Demographics
NPI:1801010905
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 1:1545 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-1122
Mailing Address - Country:US
Mailing Address - Phone:718-613-4442
Mailing Address - Fax:718-613-4885
Practice Address - Street 1:1545 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-1122
Practice Address - Country:US
Practice Address - Phone:718-613-4442
Practice Address - Fax:718-613-4885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW01401Medicare ID - Type UnspecifiedPROVIDER ID