Provider Demographics
NPI:1619957545
Name:DEENADAYALU, RENGACHARI PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:RENGACHARI
Middle Name:PAUL
Last Name:DEENADAYALU
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 1:120 W WENGER RD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322
Mailing Address - Country:US
Mailing Address - Phone:937-836-9921
Mailing Address - Fax:937-836-1298
Practice Address - Street 1:120 W WENGER RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322
Practice Address - Country:US
Practice Address - Phone:937-836-9921
Practice Address - Fax:937-836-1298
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35033785D208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0169302Medicaid
D35785OtherHUMANA
OH2080948Medicaid
OH000000011356OtherANTHEM BCBS
OH1220003OtherUNITED HEALTHCARE
OH000000011356OtherANTHEM BCBS
OH2080948Medicaid
DE0536863Medicare ID - Type Unspecified