Provider Demographics
NPI:1336219781
Name:JOHN, RENJI
Entity Type:Individual
Prefix:
First Name:RENJI
Middle Name:
Last Name:JOHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 MYERS MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-3711
Mailing Address - Country:US
Mailing Address - Phone:214-227-4353
Mailing Address - Fax:214-227-4356
Practice Address - Street 1:3016 S SHILOH RD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-2415
Practice Address - Country:US
Practice Address - Phone:214-227-4353
Practice Address - Fax:214-227-4356
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0073430332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166790901Medicaid
TX166790902Medicaid