Provider Demographics
NPI:1629045323
Name:MGBAKO, AMBROSE (MD)
Entity Type:Individual
Prefix:
First Name:AMBROSE
Middle Name:
Last Name:MGBAKO
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:PO BOX 23831
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07189-0001
Mailing Address - Country:US
Mailing Address - Phone:973-971-5595
Mailing Address - Fax:
Practice Address - Street 1:1 BAY AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4837
Practice Address - Country:US
Practice Address - Phone:973-971-5595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA062563002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1488902Medicaid
NJ452163YA79Medicare PIN
NJ1488902Medicaid
NJC55294Medicare UPIN