Provider Demographics
NPI:1497373088
Name:RENZ, TAYLOR (OD)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:RENZ
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 1:11225 HURON LN STE 200A
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-1861
Mailing Address - Country:US
Mailing Address - Phone:501-268-5808
Mailing Address - Fax:501-305-3370
Practice Address - Street 1:1225 W BEEBE CAPPS EXPY
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-5179
Practice Address - Country:US
Practice Address - Phone:501-268-5808
Practice Address - Fax:501-305-3370
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2817152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR242872722Medicaid