Provider Demographics
NPI:1265456776
Name:RENCKEN, INGO O (MD)
Entity Type:Individual
Prefix:DR
First Name:INGO
Middle Name:O
Last Name:RENCKEN
Suffix:
Gender:M
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:PO BOX 3222
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-0293
Mailing Address - Country:US
Mailing Address - Phone:707-261-7822
Mailing Address - Fax:707-256-3508
Practice Address - Street 1:501 PETALUMA AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4215
Practice Address - Country:US
Practice Address - Phone:707-829-4360
Practice Address - Fax:707-829-4013
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA564772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A564770Medicaid
00A564771Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER ID
CA00A564770Medicaid