Provider Demographics
NPI:1346205705
Name:RENNER, CARL JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:JOSEPH
Last Name:RENNER
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 1:288 BOULEVARD STE 2
Mailing Address - Street 2:
Mailing Address - City:HASBROUCK HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07604-1319
Mailing Address - Country:US
Mailing Address - Phone:201-288-6781
Mailing Address - Fax:201-288-2734
Practice Address - Street 1:288 BOULEVARD STE 2
Practice Address - Street 2:
Practice Address - City:HASBROUCK HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07604-1319
Practice Address - Country:US
Practice Address - Phone:201-288-6781
Practice Address - Fax:201-288-2734
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03936900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1570501Medicaid
NJ1570501Medicaid
027781Medicare PIN