Provider Demographics
NPI:1568079978
Name:CARMEN-WIJBENGA, MATTHEW (MPH, RDN)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:CARMEN-WIJBENGA
Suffix:
Gender:M
Credentials:MPH, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 TENNEY RD
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1316
Mailing Address - Country:US
Mailing Address - Phone:862-216-7987
Mailing Address - Fax:
Practice Address - Street 1:10 TENNEY RD
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1316
Practice Address - Country:US
Practice Address - Phone:862-216-7987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ86171763133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered