1174909469 NPI number — DEVEREUX FOUNDATION

Table of content: JOHANNA JACQUELINE GONZALEZ MEJIA M.D. (NPI 1669565396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174909469 NPI number — DEVEREUX FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEVEREUX FOUNDATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174909469
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
286 MANTUA GROVE RD
Provider Second Line Business Mailing Address:
BUILDING #4
Provider Business Mailing Address City Name:
WEST DEPTFORD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08066-1738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-599-6400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
370 CAMPUS DR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08873-1128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-599-6400
Provider Business Practice Location Address Fax Number:
856-599-6404
Provider Enumeration Date:
08/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CIRUCCI
Authorized Official First Name:
CAROLE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF FINANCE
Authorized Official Telephone Number:
610-542-3084

Provider Taxonomy Codes

  • Taxonomy code: 320900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0399507 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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