Provider Demographics
NPI:1215183108
Name:S. DESIDERIO PENSO MD PA
Entity Type:Organization
Organization Name:S. DESIDERIO PENSO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SILVESTRE
Authorized Official - Middle Name:DESIDERIO
Authorized Official - Last Name:PENSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-645-3333
Mailing Address - Street 1:1100 CLEMATIS AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08232-3302
Mailing Address - Country:US
Mailing Address - Phone:609-645-3333
Mailing Address - Fax:
Practice Address - Street 1:1 EVERGREEN RD
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1344
Practice Address - Country:US
Practice Address - Phone:609-645-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28628208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3234100Medicaid
NJ451025Medicare PIN