Healthcare Provider Details

I. General information

NPI: 1336328053
Provider Name (Legal Business Name): I CHANMIN MD MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 KENSINGTON ST
BROOKLYN NY
11235-3025
US

IV. Provider business mailing address

130 KENSINGTON ST
BROOKLYN NY
11235-3025
US

V. Phone/Fax

Practice location:
  • Phone: 718-666-2248
  • Fax:
Mailing address:
  • Phone: 718-666-2248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number219338
License Number StateNY

VIII. Authorized Official

Name: IGOR CHANMIN
Title or Position: PRESIDENT
Credential:
Phone: 718-666-2248