Provider Demographics
NPI:1700084191
Name:RENGANATHAN, USHA (MD)
Entity Type:Individual
Prefix:
First Name:USHA
Middle Name:
Last Name:RENGANATHAN
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 1:20079 STONE OAK PKWY STE 1105485
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-6942
Mailing Address - Country:US
Mailing Address - Phone:210-201-4590
Mailing Address - Fax:
Practice Address - Street 1:1791 HIGHWAY 64 E
Practice Address - Street 2:
Practice Address - City:ANAMOSA
Practice Address - State:IA
Practice Address - Zip Code:52205-2112
Practice Address - Country:US
Practice Address - Phone:319-462-6043
Practice Address - Fax:319-462-6043
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-8188207Q00000X
IA38862207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1700084191Medicaid
IA1700084191Medicaid