Provider Demographics
NPI:1205825254
Name:INDRUK, WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
Last Name:INDRUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 E SHORE RD
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2026
Mailing Address - Country:US
Mailing Address - Phone:201-207-1409
Mailing Address - Fax:973-627-7010
Practice Address - Street 1:71 E SHORE RD
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2026
Practice Address - Country:US
Practice Address - Phone:201-207-1409
Practice Address - Fax:973-627-7010
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03036400207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ149556BSDMedicare ID - Type UnspecifiedMEDICARE#
NJC58298Medicare UPIN