Provider Demographics
NPI:1669914560
Name:AGLIBUT, IRA SAMANTHA (OTR)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:SAMANTHA
Last Name:AGLIBUT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 E CENTRE ST
Mailing Address - Street 2:APT 1204
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-5410
Mailing Address - Country:US
Mailing Address - Phone:862-220-0045
Mailing Address - Fax:
Practice Address - Street 1:57 E CENTRE ST
Practice Address - Street 2:APT 1204
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-5410
Practice Address - Country:US
Practice Address - Phone:862-220-0045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor