Healthcare Provider Details

I. General information

NPI: 1902393721
Provider Name (Legal Business Name): MICHAEL DOMINIC RENECLE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 12/15/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 CASTRO ST STE 421
SAN FRANCISCO CA
94114-1031
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 415-600-4900
  • Fax: 412-536-9124
Mailing address:
  • Phone: 415-600-4900
  • Fax: 415-369-1367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A22036
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: