Basic Information
| Provider Information | |||||||||
| NPI: | 1730757311 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OUT EAST MEDICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1027 46TH AVE | ||||||||
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| City: | LONG ISLAND CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111015245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123853700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3531 LONG BEACH RD | ||||||||
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| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115725700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123853700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2021 | ||||||||
| LastUpdateDate: | 06/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | BUKA | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2123853700 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOBBY BUKA, M.D., P.C. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.