Provider Demographics
NPI:1457764037
Name:RENES, NATHANIEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:JOHN
Last Name:RENES
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 1:2900 DOOLITTLE DR
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH AFB
Mailing Address - State:SD
Mailing Address - Zip Code:57706-4821
Mailing Address - Country:US
Mailing Address - Phone:605-385-3788
Mailing Address - Fax:
Practice Address - Street 1:1380 S PATRICK DR
Practice Address - Street 2:
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925-3621
Practice Address - Country:US
Practice Address - Phone:321-494-8421
Practice Address - Fax:321-494-8458
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE28990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine