Provider Demographics
NPI:1013072966
Name:RENNER, DEBRA R (OD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:R
Last Name:RENNER
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 1:1400 FORUM BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-1997
Mailing Address - Country:US
Mailing Address - Phone:573-446-0331
Mailing Address - Fax:573-446-6991
Practice Address - Street 1:1400 FORUM BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-1997
Practice Address - Country:US
Practice Address - Phone:573-446-0331
Practice Address - Fax:573-446-6991
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003068152W00000X
MO2008032353152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1013072966OtherINDIVIDUAL NPI
MO1962644732OtherGROUP NPI
MO1013072966Medicaid
MO1013072966Medicaid
MO991723001Medicare PIN
IN894060SMedicare PIN
MO1962644732OtherGROUP NPI
MO1013072966Medicaid
MOMA2784003Medicare PIN
MO1013072966OtherINDIVIDUAL NPI