Provider Demographics
NPI:1548336555
Name:LE RENARD, JEAN LOUIS (MD)
Entity type:Individual
Prefix:
First Name:JEAN LOUIS
Middle Name:
Last Name:LE RENARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 49841
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-0841
Mailing Address - Country:US
Mailing Address - Phone:310-472-6750
Mailing Address - Fax:310-471-9433
Practice Address - Street 1:153 GRANVILLE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-4224
Practice Address - Country:US
Practice Address - Phone:310-472-6750
Practice Address - Fax:310-471-9433
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA246612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A246610Medicaid
B49990Medicare UPIN
WA24661Medicare ID - Type Unspecified