Provider Demographics
NPI:1154477479
Name:RENZA, RICHARD A (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:RENZA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:CAPE MAY COURT HOUSE
Mailing Address - State:NJ
Mailing Address - Zip Code:08210-0278
Mailing Address - Country:US
Mailing Address - Phone:609-523-1331
Mailing Address - Fax:609-522-1516
Practice Address - Street 1:6410 NEW JERSEY AVE
Practice Address - Street 2:
Practice Address - City:WILDWOOD CREST
Practice Address - State:NJ
Practice Address - Zip Code:08260-1216
Practice Address - Country:US
Practice Address - Phone:609-523-1331
Practice Address - Fax:609-522-1516
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB02591800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1245503Medicaid
E06094Medicare UPIN
122823Medicare ID - Type Unspecified