Provider Demographics
NPI:1396954145
Name:FAHRENBRUCH, GRETCHEN B (MD)
Entity type:Individual
Prefix:DR
First Name:GRETCHEN
Middle Name:B
Last Name:FAHRENBRUCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:54 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON JCT
Mailing Address - State:NJ
Mailing Address - Zip Code:08550-1335
Mailing Address - Country:US
Mailing Address - Phone:609-799-1814
Mailing Address - Fax:609-799-2574
Practice Address - Street 1:54 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:PRINCETON JCT
Practice Address - State:NJ
Practice Address - Zip Code:08550-1335
Practice Address - Country:US
Practice Address - Phone:609-799-1814
Practice Address - Fax:609-799-2574
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05282300208600000X
NJMA52823207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5213801Medicare UPIN
NJ083774MSNMedicare ID - Type Unspecified