Provider Demographics
NPI:1902597891
Name:RENYO, TIMOTHY JOSEPH (D)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:RENYO
Suffix:
Gender:M
Credentials:D
Other - Prefix:
Other - First Name:TIMOTHY
Other - Middle Name:JOSEPH
Other - Last Name:RENYO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNAO, ABOC, NCLE
Mailing Address - Street 1:115 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332-9500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3159 ROUTE 9 S
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:NJ
Practice Address - Zip Code:08242-1012
Practice Address - Country:US
Practice Address - Phone:609-465-7552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTD-1786156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty