Provider Demographics
NPI:1275099699
Name:RENALDI, ADRIAN (DO)
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:
Last Name:RENALDI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 ENTERPRISE RD
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-4199
Mailing Address - Country:US
Mailing Address - Phone:575-835-4444
Mailing Address - Fax:
Practice Address - Street 1:1300 ENTERPRISE RD
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-4199
Practice Address - Country:US
Practice Address - Phone:575-835-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7031207R00000X
390200000X
NMDO2022-0006207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program