Basic Information
| Provider Information | |||||||||
| NPI: | 1720070345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IVCHENKO | ||||||||
| FirstName: | LUDMILA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 WEST GILBERT STREET | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RED BANK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077014918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322120060 | ||||||||
| FaxNumber: | 7322120061 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE HOSPITAL PLAZA | ||||||||
| Address2: | |||||||||
| City: | OLD BRIDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088573087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323604019 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 02/22/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MA07409900 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | 25MA07409900 | NJ | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0069736 | 05 | NJ | MEDICAID |