Provider Demographics
NPI:1619944469
Name:RENEKER, LARRY EARL (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:EARL
Last Name:RENEKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2622 S DAYTONA AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-4093
Mailing Address - Country:US
Mailing Address - Phone:386-503-3736
Mailing Address - Fax:844-274-1209
Practice Address - Street 1:2622 S DAYTONA AVE
Practice Address - Street 2:
Practice Address - City:FLAGLER BEACH
Practice Address - State:FL
Practice Address - Zip Code:32136-4093
Practice Address - Country:US
Practice Address - Phone:386-503-3736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7082207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG13801Medicare UPIN
FL57217AMedicare PIN