Provider Demographics
NPI:1700087020
Name:LAWRENCE J MENDITTO DPM PC
Entity Type:Organization
Organization Name:LAWRENCE J MENDITTO DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRY
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDITTO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:732-531-4545
Mailing Address - Street 1:3200 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-4567
Mailing Address - Country:US
Mailing Address - Phone:732-531-4545
Mailing Address - Fax:732-869-1246
Practice Address - Street 1:3200 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-4567
Practice Address - Country:US
Practice Address - Phone:732-531-4545
Practice Address - Fax:732-869-1246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD02106213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2271834000OtherAMERIHEALTH
NJ6080006Medicaid
NJ5030260001Medicare NSC
NJ078133Medicare ID - Type Unspecified
NJ2271834000OtherAMERIHEALTH
NJDC0804Medicare ID - Type UnspecifiedRAIL ROAD