=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326638446
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL DOCTOR DIN PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2021
-----------------------------------------------------
Last Update Date | 01/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 BROOKDALE PLZ
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11212-3139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-240-6703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 BROOKDALE PLZ ROOM LL91 RADIATION ONCOLOGY BASEMENT
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11212-3139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-240-6703
-----------------------------------------------------
Fax | 718-240-6706
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNT MANAGER
-----------------------------------------------------
Name | MS. JACQUELINE ANDREWS
-----------------------------------------------------
Credential | CMBC
-----------------------------------------------------
Telephone | 718-240-6703
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------