Provider Demographics
NPI:1801900451
Name:DANIEL R. RENUART, MD, PA
Entity type:Organization
Organization Name:DANIEL R. RENUART, MD, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:RENUART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-424-8966
Mailing Address - Street 1:2506 SAND MINE RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-3402
Mailing Address - Country:US
Mailing Address - Phone:863-424-8966
Mailing Address - Fax:863-424-8825
Practice Address - Street 1:2506 SAND MINE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-3402
Practice Address - Country:US
Practice Address - Phone:863-424-8966
Practice Address - Fax:863-424-8825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70353208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272383201Medicaid