Basic Information
| Provider Information | |||||||||
| NPI: | 1013072966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENNER | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 FORUM BLVD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652031997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734460331 | ||||||||
| FaxNumber: | 5734466991 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 FORUM BLVD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652031997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734460331 | ||||||||
| FaxNumber: | 5734466991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 08/17/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18003068 | IN | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2008032353 | MO | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1013072966 | 01 | MO | INDIVIDUAL NPI | OTHER | 1962644732 | 01 | MO | GROUP NPI | OTHER | 1013072966 | 05 | MO | MEDICAID |