Provider Demographics
NPI:1972593424
Name:RENZI, EUGENE M (MD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:M
Last Name:RENZI
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 1:159 MULLIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3615
Mailing Address - Country:US
Mailing Address - Phone:315-788-5265
Mailing Address - Fax:315-786-0973
Practice Address - Street 1:159 MULLIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3615
Practice Address - Country:US
Practice Address - Phone:315-788-5265
Practice Address - Fax:315-786-0973
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY081639174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0200570OtherGHI
NY00560045Medicaid
NY0200570OtherGHI
NYB81000Medicare UPIN