Provider Demographics
NPI:1558343756
Name:EMELLE, EMMANUEL MADUABUCHI (MD)
Entity Type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:MADUABUCHI
Last Name:EMELLE
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 1:40 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3290
Mailing Address - Country:US
Mailing Address - Phone:973-374-3544
Mailing Address - Fax:973-374-3554
Practice Address - Street 1:40 UNION AVE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3277
Practice Address - Country:US
Practice Address - Phone:973-374-3544
Practice Address - Fax:973-374-3554
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05990500208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6311601Medicaid