Provider Demographics
NPI:1760415681
Name:JUNGBLUT, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:JUNGBLUT
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 1:516 VALLEY BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07071-0000
Mailing Address - Country:US
Mailing Address - Phone:201-935-3322
Mailing Address - Fax:201-460-3698
Practice Address - Street 1:516 VALLEY BROOK AVE
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:NJ
Practice Address - Zip Code:07071-0000
Practice Address - Country:US
Practice Address - Phone:201-935-3322
Practice Address - Fax:201-460-3698
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA0403872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0036501Medicaid
NJ521875AAFMedicare PIN