Provider Demographics
NPI:1205873155
Name:DIMENNA III, JOSEPH L (DPM)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:L
Last Name:DIMENNA III
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 KINGS HWY N STE 210
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-1015
Mailing Address - Country:US
Mailing Address - Phone:908-968-9322
Mailing Address - Fax:856-667-9739
Practice Address - Street 1:496 KINGS HWY N STE 210
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1015
Practice Address - Country:US
Practice Address - Phone:908-968-9322
Practice Address - Fax:856-667-9739
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD02297213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6787606Medicaid
NJ6787606Medicaid
NJ799145Medicare ID - Type Unspecified