Provider Demographics
NPI:1992949390
Name:MARENGO, CHRISTOPHER S (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:S
Last Name:MARENGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 DEFIANCE AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5725
Mailing Address - Country:US
Mailing Address - Phone:540-797-9779
Mailing Address - Fax:
Practice Address - Street 1:101 2ND ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701
Practice Address - Country:US
Practice Address - Phone:732-363-6655
Practice Address - Fax:732-363-6656
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101245636207V00000X
NJ25MA08897800207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1992949390Medicaid
TNQ017474Medicaid
VAVVF769AMedicare PIN
VAVVF769BMedicare PIN