Provider Demographics
NPI:1982657441
Name:RENERT, WILLIAM A (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:RENERT
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:DEPT LA 21657
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-0001
Mailing Address - Country:US
Mailing Address - Phone:858-564-1400
Mailing Address - Fax:858-564-1500
Practice Address - Street 1:7777 ALVARADO ROAD
Practice Address - Street 2:SUITE 108
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-3645
Practice Address - Country:US
Practice Address - Phone:619-460-2770
Practice Address - Fax:619-460-2774
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG1401202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G140120Medicaid
CA00G140120OtherBLUE SHIELD PIN
CAWG14012AMedicare PIN
CAP00081460Medicare PIN
CA00G140120OtherBLUE SHIELD PIN
CAWG14012DMedicare PIN