Healthcare Provider Details

I. General information

NPI: 1962809897
Provider Name (Legal Business Name): INDEPENDENT LUNG ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 OAK STREET
MELBOURNE FL
32901
US

IV. Provider business mailing address

1314 OAK STREET
MELBOURNE FL
32901
US

V. Phone/Fax

Practice location:
  • Phone: 321-727-7992
  • Fax: 321-727-7664
Mailing address:
  • Phone: 321-727-7992
  • Fax: 321-727-7664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME112053
License Number StateFL

VIII. Authorized Official

Name: DR. ZAKI ELMAGHRABY
Title or Position: OWNER
Credential: MD
Phone: 321-727-7992