Provider Demographics
NPI:1427091024
Name:RENNA, THEODORE
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:RENNA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 OLD STREET RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PETERBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03458-1200
Mailing Address - Country:US
Mailing Address - Phone:603-924-7070
Mailing Address - Fax:603-924-6700
Practice Address - Street 1:454 OLD STREET RD
Practice Address - Street 2:SUITE 204
Practice Address - City:PETERBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03458-1200
Practice Address - Country:US
Practice Address - Phone:603-924-7070
Practice Address - Fax:603-924-6700
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH5884207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH6740Medicare PIN