MEDICARE: DR. IHN SOUGH LAR M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	157642	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124197892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IHN SOUGH LAR M.D.

Provider Business Mailing Address
First Line	:	3010 GRAND CONCOURSE APT L2
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10458-1534
Country	:	US
Telephone Number	:	718-365-8850
Fax Number	:	718-365-8057

Provider Business Practice Location Address
First Line	:	3010 GRAND CONCOURSE APT L2
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10458-1534
Country	:	US
Telephone Number	:	718-365-8850
Fax Number	:	718-365-8057

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	07/08/2007

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