Provider Demographics
NPI:1255382586
Name:VASU, RENGA I (MD)
Entity type:Individual
Prefix:
First Name:RENGA
Middle Name:I
Last Name:VASU
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 1:8000 CENTERVIEW PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-4227
Mailing Address - Country:US
Mailing Address - Phone:901-747-1111
Mailing Address - Fax:
Practice Address - Street 1:8000 CENTERVIEW PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-4227
Practice Address - Country:US
Practice Address - Phone:901-747-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15351174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3020723Medicaid
TN130007965Medicare PIN
TNA98445Medicare UPIN
TN3020723Medicare ID - Type Unspecified