Provider Demographics
NPI:1093752503
Name:MAYER, RENAE LYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:RENAE
Middle Name:LYNE
Last Name:MAYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8803 S 101ST EAST AVE
Mailing Address - Street 2:STE 130
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5726
Mailing Address - Country:US
Mailing Address - Phone:918-579-3850
Mailing Address - Fax:918-294-6929
Practice Address - Street 1:8803 S 101ST EAST AVE
Practice Address - Street 2:STE 130
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5726
Practice Address - Country:US
Practice Address - Phone:918-579-3850
Practice Address - Fax:918-294-6929
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22105207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100186290AMedicaid
OK100186290AMedicaid
OK325612YLV0Medicare PIN