=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053749333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LK DABIRI MEDICAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2013
-----------------------------------------------------
Last Update Date | 10/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1220 E NEW YORK AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11212-3832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-417-9733
-----------------------------------------------------
Fax | 347-627-6800
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1220 E NEW YORK AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11212-3832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-417-9733
-----------------------------------------------------
Fax | 347-627-6800
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | JAMES K IRUNGU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-353-7073
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 268264
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------