Basic Information
| Provider Information | |||||||||
| NPI: | 1336174945 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGELBACH | ||||||||
| FirstName: | LUDMILA | ||||||||
| MiddleName: | MARIA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19 | ||||||||
| Address2: | 1 ROBERT WOOD JOHNSON PLACE, MEB 212 | ||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322358120 | ||||||||
| FaxNumber: | 7322354661 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 ROUTE 72 WEST | ||||||||
| Address2: | |||||||||
| City: | MANAHAWKIN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080502412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6099788900 | ||||||||
| FaxNumber: | 6099783176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 09/20/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | 36604 | NJ | N | Other Service Providers | Contractor | 174400000X | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2067307 | 05 | NJ | MEDICAID | P00953436 | 01 | NJ | R R MCR | OTHER |