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General NPI Number Information
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NPI Number | 1184034183
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Entity Type | Organization
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Legal Business Name | MEDICAL STATE OF QUEENS
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Dates
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Enumeration Date | 04/30/2014
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Last Update Date | 10/15/2015
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Provider Practice Location Address
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Address Line | 8544 66TH RD
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City | REGO PARK
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State | NY
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Zip | 11374-5212
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Country | US
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Telephone | 718-565-6050
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Fax |
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Provider Business Mailing Address
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Address Line | 8544 66TH RD
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City | REGO PARK
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State | NY
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Zip | 11374-5212
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Country | US
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Telephone | 718-565-6050
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Fax |
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Authorized Official
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Title or Position | DR
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Name | NIKOLAI LAGODUKE
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Credential |
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Telephone | 718-554-1150
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 173000000X
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Taxonomy Name | Legal Medicine
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License Number | 233906
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License Number State | NY
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