=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710157581
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKENDER DRIZA MEDICAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2008
-----------------------------------------------------
Last Update Date | 04/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6062 PALMETTO ST
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11385-3241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-821-4443
-----------------------------------------------------
Fax | 718-821-5785
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5916 69TH AVE
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11385-4454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-417-7581
-----------------------------------------------------
Fax | 718-417-7581
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SKENDER DRIZA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 718-417-7581
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 245274
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------