Provider Demographics
NPI:1740424134
Name:MARENTIS, THEODORE COSMO (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:COSMO
Last Name:MARENTIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6501 COYLE AVE
Practice Address - Street 2:NUCLEAR MEDICINE
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0306
Practice Address - Country:US
Practice Address - Phone:916-537-5208
Practice Address - Fax:916-537-5425
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2014-09-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI43010938102085R0202X
CAA1314132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology