Provider Demographics
NPI:1336149400
Name:TAMIRISA, RENU (MD)
Entity Type:Individual
Prefix:
First Name:RENU
Middle Name:
Last Name:TAMIRISA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3519 TOWN CENTER BLVD S
Mailing Address - Street 2:#300
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-1000
Mailing Address - Country:US
Mailing Address - Phone:281-277-3300
Mailing Address - Fax:281-277-0158
Practice Address - Street 1:3519 TOWN CENTER BLVD S
Practice Address - Street 2:#300
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-1000
Practice Address - Country:US
Practice Address - Phone:281-277-3300
Practice Address - Fax:281-277-0158
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2826207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148681301Medicaid
C22458Medicare UPIN
TX148681301Medicaid