Provider Demographics
NPI:1538138847
Name:VENTRELLA, SUSAN M (DO)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:VENTRELLA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 FRONT ST
Mailing Address - Street 2:PO BOX 577
Mailing Address - City:ELMER
Mailing Address - State:NJ
Mailing Address - Zip Code:08318-2143
Mailing Address - Country:US
Mailing Address - Phone:856-358-0770
Mailing Address - Fax:856-358-0108
Practice Address - Street 1:330 FRONT ST
Practice Address - Street 2:
Practice Address - City:ELMER
Practice Address - State:NJ
Practice Address - Zip Code:08318-2143
Practice Address - Country:US
Practice Address - Phone:856-358-0770
Practice Address - Fax:856-358-0108
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB57186207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6246907Medicaid
NJ6246907Medicaid
NJVE515020Medicare ID - Type UnspecifiedMEDICARE