Provider Demographics
NPI:1386895423
Name:LAWRENCE O. EGBUCHULAM, M.D., P.C.
Entity type:Organization
Organization Name:LAWRENCE O. EGBUCHULAM, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:EGBUCHULAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-674-6318
Mailing Address - Street 1:84 SANFORD ST
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-1927
Mailing Address - Country:US
Mailing Address - Phone:973-674-6318
Mailing Address - Fax:973-674-8953
Practice Address - Street 1:84 SANFORD ST
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-1927
Practice Address - Country:US
Practice Address - Phone:973-674-6318
Practice Address - Fax:973-674-8953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46686174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2496500Medicaid