=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497815773
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYUDMILA PEKARSKY M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 356 DELAWARE AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10305-2306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-667-6354
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 MANOR DR
-----------------------------------------------------
City | MANALAPAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07726-3120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-972-2805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080A0000X
-----------------------------------------------------
Taxonomy Name | Pediatric Adolescent Medicine Physician
-----------------------------------------------------
License Number | 167337
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------