=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386879310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABDUL S BANGURA M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2009
-----------------------------------------------------
Last Update Date | 07/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305 LATHAM DR
-----------------------------------------------------
City | WARNER ROBINS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31088-2126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-287-2228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 305 LATHAM DR
-----------------------------------------------------
City | WARNER ROBINS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31088-2126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-287-2228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 065932
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------