Provider Demographics
NPI:1639227804
Name:MECCA, MAURO ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:MAURO
Middle Name:ANTHONY
Last Name:MECCA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 SAWYER CT
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07401-1339
Mailing Address - Country:US
Mailing Address - Phone:201-236-2446
Mailing Address - Fax:973-778-3304
Practice Address - Street 1:1 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644-2240
Practice Address - Country:US
Practice Address - Phone:973-778-3303
Practice Address - Fax:973-778-3304
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03656200207R00000X
NY132599207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C52411Medicare UPIN
000870Medicare ID - Type Unspecified