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General NPI Number Information
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NPI Number | 1134765258
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Entity Type | Individual
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Provider Name | IVAN JOHN PHILIPOSE
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Gender | Male
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Dates
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Enumeration Date | 11/24/2019
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Last Update Date | 11/24/2019
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Provider Practice Location Address
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Address Line | 1410 BROADWAY
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City | NEW HYDE PARK
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State | NY
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Zip | 11040-4224
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Country | US
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Telephone | 516-902-6492
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Fax |
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Provider Business Mailing Address
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Address Line | 910 SUMMER ST
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City | STAMFORD
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State | CT
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Zip | 06905-5502
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Country | US
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Telephone | 516-902-6492
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | PCT.0014251
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License Number State | CT
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