Basic Information
| Provider Information | |||||||||
| NPI: | 1164411773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DERENZI | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 416457 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022416457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443621735 | ||||||||
| FaxNumber: | 9732907495 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN LAKES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070461723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733347700 | ||||||||
| FaxNumber: | 9734025847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | MA059234 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | MA59234 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 6565701 | 05 | NJ | MEDICAID |