Provider Demographics
NPI:1710943931
Name:BACHARACH, MOSHE (MD)
Entity Type:Individual
Prefix:
First Name:MOSHE
Middle Name:
Last Name:BACHARACH
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 1:1166 RIVER AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5600
Mailing Address - Country:US
Mailing Address - Phone:732-905-4142
Mailing Address - Fax:
Practice Address - Street 1:1166 RIVER AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5600
Practice Address - Country:US
Practice Address - Phone:732-905-4142
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46194174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC57053Medicare UPIN
NJ560913RRGMedicare ID - Type Unspecified