Provider Demographics
NPI:1477584100
Name:PENCZAK, SUSAN H (DC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:PENCZAK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 STATE ROUTE 35
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-3539
Mailing Address - Country:US
Mailing Address - Phone:732-974-7022
Mailing Address - Fax:732-974-7023
Practice Address - Street 1:2041 STATE ROUTE 35
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-3539
Practice Address - Country:US
Practice Address - Phone:732-974-7022
Practice Address - Fax:732-974-7023
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00554100111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
2281138000OtherAMERIHEALTH PRACTIC HMO I
2273901000OtherAMERIHEALTH INDIV. HMO ID
P3271421OtherOXFORD
NJ084038Medicare PIN
2281138000OtherAMERIHEALTH PRACTIC HMO I