Provider Demographics
NPI:1710305677
Name:RENNER, KEVIN M (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:RENNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 PHYSICIANS PARK DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901
Mailing Address - Country:US
Mailing Address - Phone:573-785-4546
Mailing Address - Fax:573-785-6959
Practice Address - Street 1:225 PHYSICIANS PARK STE 102
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3918
Practice Address - Country:US
Practice Address - Phone:573-785-4546
Practice Address - Fax:573-785-6959
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017016516213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2017016516OtherMO LICENSE