Provider Demographics
NPI:1154318111
Name:MENA, MARIA GUTIERREZ (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:GUTIERREZ
Last Name:MENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARIA
Other - Middle Name:B GUTIERREZ
Other - Last Name:MENA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:418 57TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-2120
Mailing Address - Country:US
Mailing Address - Phone:201-868-5391
Mailing Address - Fax:201-453-1054
Practice Address - Street 1:418 57TH ST
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-2120
Practice Address - Country:US
Practice Address - Phone:201-868-5391
Practice Address - Fax:201-453-1054
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03403300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1258605Medicaid