Provider Demographics
NPI:1538485297
Name:RENNER, DANIEL MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:MATTHEW
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 1:95 S PAGOSA BLVD
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-8329
Mailing Address - Country:US
Mailing Address - Phone:970-507-3781
Mailing Address - Fax:970-731-3708
Practice Address - Street 1:95 S PAGOSA BLVD
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-8329
Practice Address - Country:US
Practice Address - Phone:970-731-3700
Practice Address - Fax:970-731-3708
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-00828207P00000X
CODR.0053567207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine