Provider Demographics
NPI:1932109352
Name:RENIVA, AMANDO A (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDO
Middle Name:A
Last Name:RENIVA
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 1:1125 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4814
Mailing Address - Country:US
Mailing Address - Phone:847-698-0661
Mailing Address - Fax:
Practice Address - Street 1:6315 N MILWAUKEE AVE # A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-3760
Practice Address - Country:US
Practice Address - Phone:847-679-1668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2016-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105799207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
K01460OtherMEDICARE ID #
1932109352OtherNPI INDIVIDUAL
IL036105799Medicaid
K01460OtherMEDICARE ID #