Provider Demographics
NPI:1154363943
Name:KALEMBA, JOHANNA MARIE DEL'RE (MD)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:MARIE DEL'RE
Last Name:KALEMBA
Suffix:
Gender:F
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:PO BOX 14068
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-0789
Mailing Address - Country:US
Mailing Address - Phone:631-952-5701
Mailing Address - Fax:631-952-5740
Practice Address - Street 1:455 JACK MARTIN BLVD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7732
Practice Address - Country:US
Practice Address - Phone:732-840-6500
Practice Address - Fax:732-840-6459
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA065745002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0001228Medicaid
NJ065434CEAMedicare PIN
NJ0001228Medicaid