Basic Information
| Provider Information | |||||||||
| NPI: | 1982657441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENERT | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 21657 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911850001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585641400 | ||||||||
| FaxNumber: | 8585641500 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 ALVARADO ROAD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919413645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194602770 | ||||||||
| FaxNumber: | 6194602774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G140120 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G140120 | 05 | CA | MEDICAID | 00G140120 | 01 | CA | BLUE SHIELD PIN | OTHER |