Provider Demographics
NPI:1104396241
Name:NDEGWA RENNEBOHM, WILLIAM MAX (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MAX
Last Name:NDEGWA RENNEBOHM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:MAX
Other - Last Name:RENNEBOHM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15477 VENTURA BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3068
Mailing Address - Country:US
Mailing Address - Phone:188-907-0322
Mailing Address - Fax:188-907-0360
Practice Address - Street 1:15477 VENTURA BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3068
Practice Address - Country:US
Practice Address - Phone:188-907-0322
Practice Address - Fax:188-907-0360
Is Sole Proprietor?:No
Enumeration Date:2018-12-02
Last Update Date:2024-02-08
Deactivation Date:2019-11-13
Deactivation Code:
Reactivation Date:2020-04-03
Provider Licenses
StateLicense IDTaxonomies
WAMD61317317207Q00000X
390200000X
CAA189007207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program