Healthcare Provider Details

I. General information

NPI: 1154318111
Provider Name (Legal Business Name): MARIA GUTIERREZ MENA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: MARIA B GUTIERREZ MENA M.D.

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 57TH ST
WEST NEW YORK NJ
07093-2120
US

IV. Provider business mailing address

418 57TH ST
WEST NEW YORK NJ
07093-2120
US

V. Phone/Fax

Practice location:
  • Phone: 201-868-5391
  • Fax: 201-453-1054
Mailing address:
  • Phone: 201-868-5391
  • Fax: 201-453-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA03403300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: