MEDICARE: LUNG DOCTOR LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RS0012X	Sleep Medicine (Internal Medicine) Physician	MA58862	NJ
2	207RP1001X	Pulmonary Disease Physician	MA58862	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194770966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUNG DOCTOR LLC

Provider Business Mailing Address
First Line	:	722 SANFORD AVE
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07106-3627
Country	:	US
Telephone Number	:	973-399-9090
Fax Number	:

Provider Business Practice Location Address
First Line	:	722 SANFORD AVE
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07106-3627
Country	:	US
Telephone Number	:	973-399-9090
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AKINGBOJU GBAYSOMORE
Credential	:	DO
Telephone Number	:	973-399-9090

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	07/30/2008

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Directions to “LUNG DOCTOR LLC ” Practice Location

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