Provider Demographics
NPI:1861427064
Name:RENAUD, DUSTIN D (PT)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:D
Last Name:RENAUD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BUTLER DR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4862
Mailing Address - Country:US
Mailing Address - Phone:401-277-0790
Mailing Address - Fax:
Practice Address - Street 1:2 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3236
Practice Address - Country:US
Practice Address - Phone:401-277-0790
Practice Address - Fax:401-277-0795
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01590174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007056987Medicare ID - Type Unspecified