Healthcare Provider Details

I. General information

NPI: 1346629334
Provider Name (Legal Business Name): ARTUR IVCHENKO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 JACK MARTIN BLVD
BRICK NJ
08724-7732
US

IV. Provider business mailing address

425 JACK MARTIN BLVD
BRICK NJ
08724-7732
US

V. Phone/Fax

Practice location:
  • Phone: 732-840-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA11302300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: