Provider Demographics
NPI:1194583963
Name:RENAISSANCE MEDICAL MANAGEMENT LLC
Entity type:Organization
Organization Name:RENAISSANCE MEDICAL MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-205-7424
Mailing Address - Street 1:941 W I-35 FRONTAGE ROAD STE 116 PMB 203
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034
Mailing Address - Country:US
Mailing Address - Phone:405-285-6901
Mailing Address - Fax:405-285-6902
Practice Address - Street 1:3509 FRENCH PARK DR STE E
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-7291
Practice Address - Country:US
Practice Address - Phone:405-285-6901
Practice Address - Fax:405-285-6902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty