Provider Demographics
NPI:1417163999
Name:IGNATIUS, RENJITHA TOM (MD)
Entity Type:Individual
Prefix:
First Name:RENJITHA
Middle Name:TOM
Last Name:IGNATIUS
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:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:4051 UPPER CREEK DR STE 103B
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-6825
Practice Address - Country:US
Practice Address - Phone:813-633-3955
Practice Address - Fax:813-633-0441
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME120370207RX0202X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012858200Medicaid
FLME120370OtherLICENSE
FLME120370OtherLICENSE