Basic Information
| Provider Information | |||||||||
| NPI: | 1114975679 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIRENZO | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7000 ATRIUM WAY | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | MOUNT LAUREL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080543917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562916818 | ||||||||
| FaxNumber: | 8562916819 | ||||||||
| Practice Location | |||||||||
| Address1: | 2225 E EVESHAM RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080431557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567954330 | ||||||||
| FaxNumber: | 8563253704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 03/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MA4363600 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1481304 | 05 | NJ | MEDICAID |