Healthcare Provider Details

I. General information

NPI: 1114975679
Provider Name (Legal Business Name): ROBERT M DIRENZO M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 03/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 E EVESHAM RD SUITE 101
VOORHEES NJ
08043-1557
US

IV. Provider business mailing address

7000 ATRIUM WAY SUITE 6
MOUNT LAUREL NJ
08054-3917
US

V. Phone/Fax

Practice location:
  • Phone: 856-795-4330
  • Fax: 856-325-3704
Mailing address:
  • Phone: 856-291-6818
  • Fax: 856-291-6819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA4363600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: