Provider Demographics
NPI:1417201021
Name:VASENA MARENGO, MARIA JOSE (#39)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:JOSE
Last Name:VASENA MARENGO
Suffix:
Gender:F
Credentials:#39
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-1233
Mailing Address - Country:US
Mailing Address - Phone:201-529-1595
Mailing Address - Fax:973-826-5064
Practice Address - Street 1:330 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NJ
Practice Address - Zip Code:07506-2506
Practice Address - Country:US
Practice Address - Phone:973-841-5112
Practice Address - Fax:973-826-5064
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-04
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09694700208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics