Provider Demographics
NPI:1447390737
Name:RENKEN, WOLFGANG HEINRICH (OD)
Entity Type:Individual
Prefix:MR
First Name:WOLFGANG
Middle Name:HEINRICH
Last Name:RENKEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WASCO
Mailing Address - State:CA
Mailing Address - Zip Code:93280-1732
Mailing Address - Country:US
Mailing Address - Phone:661-758-6320
Mailing Address - Fax:661-758-6332
Practice Address - Street 1:1301 7TH ST
Practice Address - Street 2:
Practice Address - City:WASCO
Practice Address - State:CA
Practice Address - Zip Code:93280-1732
Practice Address - Country:US
Practice Address - Phone:661-758-6320
Practice Address - Fax:661-758-6332
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4802T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA110059OtherEYE MED VISION CARE
CASD0048020Medicaid
CA3582OtherMEDICAL EYE SERVICES
CASD0048020Medicaid
CA3582OtherMEDICAL EYE SERVICES