Healthcare Provider Details

I. General information

NPI: 1376746990
Provider Name (Legal Business Name): MICHELLE MARIE MARESCA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2007
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-5329
  • Fax: 551-996-0115
Mailing address:
  • Phone: 551-996-5329
  • Fax: 551-996-0115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC10009448
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT190824
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC7-0003807
License Number StateDE
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberC10009448
License Number StateDE
# 5
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number25MA09533900
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: