MEDICARE: LAMBODARA LLC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1902376130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAMBODARA LLC

Provider Business Mailing Address
First Line	:	1638 CARROLL RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845
Country	:	US
Telephone Number	:	321-626-3044
Fax Number	:

Provider Business Practice Location Address
First Line	:	1638 CARROLL RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845
Country	:	US
Telephone Number	:	321-626-3044
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	KAMLESHKUMAR R PATEL
Credential	:	MD
Telephone Number	:	321-626-3044

Provider Enumeration Date	:	11/30/2018
Last Update Date	:	11/30/2018

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