Provider Demographics
NPI:1891782348
Name:MOOTHATHU, RENUKA S (MD)
Entity Type:Individual
Prefix:DR
First Name:RENUKA
Middle Name:S
Last Name:MOOTHATHU
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:5855 BREMO RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1926
Mailing Address - Country:US
Mailing Address - Phone:804-282-0655
Mailing Address - Fax:804-282-0717
Practice Address - Street 1:5855 BREMO RD
Practice Address - Street 2:SUITE 210
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1926
Practice Address - Country:US
Practice Address - Phone:804-282-0655
Practice Address - Fax:804-282-0717
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA01010531022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG18506Medicare UPIN