Healthcare Provider Details

I. General information

NPI: 1205912813
Provider Name (Legal Business Name): METHODIST OUTRACH LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 6TH ST
BROOKLYN NY
11215-3609
US

IV. Provider business mailing address

1900 HEMPSTEAD TPKE SUITE 500
EAST MEADOW NY
11554-1724
US

V. Phone/Fax

Practice location:
  • Phone: 718-780-3016
  • Fax:
Mailing address:
  • Phone: 516-542-1090
  • Fax: 516-794-8165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: RABIA MIR
Title or Position: DIRECTOR
Credential: MD
Phone: 718-780-3016