Provider Demographics
NPI:1508974627
Name:MEDRANO, RENATO (MD)
Entity Type:Individual
Prefix:DR
First Name:RENATO
Middle Name:
Last Name:MEDRANO
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 1:38 HEATHER LOCH
Mailing Address - Street 2:
Mailing Address - City:NORTH YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04097-6431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:144 FORE ST
Practice Address - Street 2:PORTLAND VA CLINIC
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4843
Practice Address - Country:US
Practice Address - Phone:207-771-3500
Practice Address - Fax:207-771-3577
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013736207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEF72504Medicare UPIN