Provider Demographics
NPI:1124047253
Name:BRENZA, DANIELLE (DO)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:BRENZA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BRIGGS RD
Mailing Address - Street 2:210
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-4100
Mailing Address - Country:US
Mailing Address - Phone:856-231-4774
Mailing Address - Fax:856-231-9699
Practice Address - Street 1:11 PARKE PLACE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2664
Practice Address - Country:US
Practice Address - Phone:856-218-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB70308207P00000X
NJ25MB07030800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ90000011100OtherAMERICHOICE
NJ2138629000OtherAMERIHEALTH
NJ222137644OtherCHAMPUS/TRICARE
NJ8920401Medicaid
NJ222137644OtherBCBSNJ
H63839Medicare UPIN
NJ058814Medicare ID - Type Unspecified