Provider Demographics
NPI:1922042787
Name:LAX, GLORIA M (MD)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:M
Last Name:LAX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:307 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2739
Mailing Address - Country:US
Mailing Address - Phone:856-686-4300
Mailing Address - Fax:
Practice Address - Street 1:99 BEAUVOIR AVE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3533
Practice Address - Country:US
Practice Address - Phone:908-522-2232
Practice Address - Fax:908-522-0227
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA73539207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8999708Medicaid
NJ8999708Medicaid
NJ076720Medicare ID - Type Unspecified