Provider Demographics
NPI:1851944748
Name:TYAGARAJ, RENU (OD)
Entity Type:Individual
Prefix:
First Name:RENU
Middle Name:
Last Name:TYAGARAJ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WATER STREET 2ND FLOOR CRED DEPT
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0010
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:206-20 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:CAMBRIA HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11411-1524
Practice Address - Country:US
Practice Address - Phone:718-479-6600
Practice Address - Fax:718-264-7080
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTV009022152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty