Provider Demographics
NPI:1174870034
Name:AMBALU, NAOMI (DO)
Entity type:Individual
Prefix:DR
First Name:NAOMI
Middle Name:
Last Name:AMBALU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 KING GEORGE RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059
Mailing Address - Country:US
Mailing Address - Phone:908-647-8847
Mailing Address - Fax:
Practice Address - Street 1:266 KING GEORGE RD STE G
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-5187
Practice Address - Country:US
Practice Address - Phone:908-647-8847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MB097443002084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program