Basic Information
| Provider Information | |||||||||
| NPI: | 1124047253 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRENZA | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 BRIGGS RD | ||||||||
| Address2: | 210 | ||||||||
| City: | MOUNT LAUREL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080544100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562314774 | ||||||||
| FaxNumber: | 8562319699 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 PARKE PLACE BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080802664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562184848 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 02/08/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MB70308 | NJ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 25MB07030800 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 90000011100 | 01 | NJ | AMERICHOICE | OTHER | 2138629000 | 01 | NJ | AMERIHEALTH | OTHER | 222137644 | 01 | NJ | CHAMPUS/TRICARE | OTHER | 8920401 | 05 | NJ | MEDICAID | 222137644 | 01 | NJ | BCBSNJ | OTHER |