Healthcare Provider Details

I. General information

NPI: 1174744221
Provider Name (Legal Business Name): IMAD JOHN BAKOSS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 71ST ST
BROOKLYN NY
11204-5526
US

IV. Provider business mailing address

2165 71ST ST
BROOKLYN NY
11204-5526
US

V. Phone/Fax

Practice location:
  • Phone: 718-621-7100
  • Fax: 718-621-7103
Mailing address:
  • Phone: 718-621-7100
  • Fax: 718-621-7103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number129319
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number129319
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number129319
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number129319
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number129319
License Number StateNY

VIII. Authorized Official

Name: IMAD J BAKOSS
Title or Position: OWNER
Credential: M.D.
Phone: 718-621-7100