Provider Demographics
NPI:1780658187
Name:IGBANUGO, ANSELM OKECHUKWU (MD)
Entity Type:Individual
Prefix:DR
First Name:ANSELM
Middle Name:OKECHUKWU
Last Name:IGBANUGO
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 2136
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08754-2136
Mailing Address - Country:US
Mailing Address - Phone:732-281-3100
Mailing Address - Fax:732-281-3311
Practice Address - Street 1:508 LAKEHURST RD
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-8000
Practice Address - Country:US
Practice Address - Phone:732-281-3100
Practice Address - Fax:732-281-3311
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA59719207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ822437Medicaid
G20204Medicare UPIN
NJ822437Medicaid