Basic Information
Provider Information | |||||||||
NPI: | 1356429633 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MENZA | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 66 W GILBERT ST | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | TINTON FALLS | ||||||||
State: | NJ | ||||||||
PostalCode: | 077014947 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7322350051 | ||||||||
FaxNumber: | 7322120713 | ||||||||
Practice Location | |||||||||
Address1: | 671 HOES LN | ||||||||
Address2: |   | ||||||||
City: | PISCATAWAY | ||||||||
State: | NJ | ||||||||
PostalCode: | 088545627 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8009695300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2006 | ||||||||
LastUpdateDate: | 11/18/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 25MA04898400 | NJ | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 2167905 | 05 | NJ |   | MEDICAID |