=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477545572
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER L MENGER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2005
-----------------------------------------------------
Last Update Date | 01/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7809 MYRTLE AVE
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11385-7439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-386-1818
-----------------------------------------------------
Fax | 718-821-1852
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7809 MYRTLE AVE
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11385-7439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-386-1818
-----------------------------------------------------
Fax | 718-821-1852
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 163197
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------