Provider Demographics
NPI:1457347890
Name:RENSTON, JEFFREY PAUL (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:PAUL
Last Name:RENSTON
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 1:211 LAKE COVE CT
Mailing Address - Street 2:
Mailing Address - City:BRATENAHL
Mailing Address - State:OH
Mailing Address - Zip Code:44108-1074
Mailing Address - Country:US
Mailing Address - Phone:216-761-5931
Mailing Address - Fax:
Practice Address - Street 1:1611 S GREEN RD
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-4136
Practice Address - Country:US
Practice Address - Phone:216-297-3168
Practice Address - Fax:216-297-3169
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055582207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0882755Medicaid
OHRE0720204Medicare PIN
OH0882755Medicaid