Provider Demographics
NPI:1639505506
Name:DOMENACK CASAS, RENATO (MD)
Entity Type:Individual
Prefix:
First Name:RENATO
Middle Name:
Last Name:DOMENACK CASAS
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 1:2716 KENT DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-2922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:406 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SMETHPORT
Practice Address - State:PA
Practice Address - Zip Code:16749-1277
Practice Address - Country:US
Practice Address - Phone:814-362-8356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD449690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine