Provider Demographics
NPI:1841201183
Name:RENSLO, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:RENSLO
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 1:21840 NORMANDIE AVE
Mailing Address - Street 2:STE. 500
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2047
Mailing Address - Country:US
Mailing Address - Phone:310-222-5163
Mailing Address - Fax:310-222-5173
Practice Address - Street 1:21840 NORMANDIE AVE
Practice Address - Street 2:STE. 500
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2047
Practice Address - Country:US
Practice Address - Phone:310-222-5163
Practice Address - Fax:310-222-5173
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG600832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G600830Medicaid
CAE87680Medicare UPIN
CAWG60083GMedicare ID - Type UnspecifiedPPIN
CAWG60083FMedicare ID - Type UnspecifiedPPIN
CA00G600830Medicaid