Provider Demographics
NPI:1578191391
Name:RENZ, ANDIA MITRI (MD)
Entity type:Individual
Prefix:
First Name:ANDIA
Middle Name:MITRI
Last Name:RENZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 UNDERHILL BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-3416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:575 UNDERHILL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-3416
Practice Address - Country:US
Practice Address - Phone:516-921-2294
Practice Address - Fax:516-921-1206
Is Sole Proprietor?:No
Enumeration Date:2020-03-28
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.075573207R00000X
NY32930901207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine