Provider Demographics
NPI:1699857011
Name:MEDENILLA, ROSENIO R (MD)
Entity Type:Individual
Prefix:
First Name:ROSENIO
Middle Name:R
Last Name:MEDENILLA
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 1:1301 ROUTE 72 W
Mailing Address - Street 2:SUITE 240
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2417
Mailing Address - Country:US
Mailing Address - Phone:609-597-7394
Mailing Address - Fax:609-597-6833
Practice Address - Street 1:1301 ROUTE 72 W
Practice Address - Street 2:SUITE 240
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2417
Practice Address - Country:US
Practice Address - Phone:609-597-7394
Practice Address - Fax:609-597-6833
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA67504207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJMA67504Medicaid
NJ223016655OtherTAX ID
NJG77002Medicare UPIN
NJ223016655OtherTAX ID