Provider Demographics
NPI:1871683987
Name:CERGNUL, IRENE GRGURICH (MD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:GRGURICH
Last Name:CERGNUL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:G
Other - Last Name:CERGNUL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:35 BOONTON AVE
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-2941
Mailing Address - Country:US
Mailing Address - Phone:973-261-6987
Mailing Address - Fax:
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:16TH FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:718-518-5669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY234693OtherLICENSE