Provider Demographics
NPI:1811991292
Name:DIRENZO, JOSEPH P JR (DO)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:P
Last Name:DIRENZO
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 W OREGON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-4421
Mailing Address - Country:US
Mailing Address - Phone:215-389-7766
Mailing Address - Fax:215-389-0227
Practice Address - Street 1:1028 W OREGON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-4421
Practice Address - Country:US
Practice Address - Phone:215-389-7766
Practice Address - Fax:215-389-0227
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2021-07-15
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
PAOS009019L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015699730001Medicaid