Provider Demographics
NPI:1194770966
Name:LUNG DOCTOR LLC
Entity type:Organization
Organization Name:LUNG DOCTOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AKINGBOJU
Authorized Official - Middle Name:
Authorized Official - Last Name:GBAYSOMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-399-9090
Mailing Address - Street 1:722 SANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106-3627
Mailing Address - Country:US
Mailing Address - Phone:973-399-9090
Mailing Address - Fax:
Practice Address - Street 1:722 SANFORD AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07106-3627
Practice Address - Country:US
Practice Address - Phone:973-399-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA58862207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7240406Medicaid
NJ7240406Medicaid
NJF71216Medicare UPIN