Provider Demographics
NPI:1588639801
Name:RENIVA, FAUSTINO A JR (MD)
Entity Type:Individual
Prefix:DR
First Name:FAUSTINO
Middle Name:A
Last Name:RENIVA
Suffix:JR
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 1:633 BATTLEFIELD BLVD S
Mailing Address - Street 2:STE 300
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-4800
Mailing Address - Country:US
Mailing Address - Phone:757-233-4700
Mailing Address - Fax:757-233-4701
Practice Address - Street 1:249 NEWTOWN RD S
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502
Practice Address - Country:US
Practice Address - Phone:757-892-5520
Practice Address - Fax:757-892-5521
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051148207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5824052Medicaid
F95558Medicare UPIN