Provider Demographics
NPI:1679818967
Name:ILAGAN, GREGG
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:
Last Name:ILAGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MARTIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-2628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1750 DEPTFORD CENTER RD
Practice Address - Street 2:
Practice Address - City:DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-5222
Practice Address - Country:US
Practice Address - Phone:856-384-2089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MG00066500237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist