Healthcare Provider Details

I. General information

NPI: 1902267941
Provider Name (Legal Business Name): RENALD VALDEMAR MT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2016
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 AZALIA CT
HEMPSTEAD NY
11550-1101
US

IV. Provider business mailing address

30 LINDEN BLVD A4
BROOKLYN NY
11226-3178
US

V. Phone/Fax

Practice location:
  • Phone: 347-265-8656
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number156692
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number017653
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: