Provider Demographics
NPI:1114678646
Name:DERENZO, MICHAEL PASQUALE (LDO)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PASQUALE
Last Name:DERENZO
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HARMON DR
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-5103
Mailing Address - Country:US
Mailing Address - Phone:856-228-1000
Mailing Address - Fax:
Practice Address - Street 1:1 HARMON DR
Practice Address - Street 2:
Practice Address - City:BLACKWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08012-5103
Practice Address - Country:US
Practice Address - Phone:856-228-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-17
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006765156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006765OtherLICENSED OPTICIAN