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General NPI Number Information
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NPI Number | 1194583963
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Entity Type | Organization
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Legal Business Name | RENAISSANCE MEDICAL MANAGEMENT LLC
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Dates
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Enumeration Date | 03/07/2024
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Last Update Date | 03/07/2024
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Provider Practice Location Address
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Address Line | 3509 FRENCH PARK DR STE E
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City | EDMOND
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State | OK
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Zip | 73034-7291
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Country | US
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Telephone | 405-285-6901
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Fax | 405-285-6902
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Provider Business Mailing Address
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Address Line | 941 W I-35 FRONTAGE ROAD STE 116 PMB 203
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City | EDMOND
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State | OK
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Zip | 73034
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Country | US
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Telephone | 405-285-6901
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Fax | 405-285-6902
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Authorized Official
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Title or Position | OWNER, MEDICAL DOCTOR
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Name | JEFFREY LYNN WATTS
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Credential | MD
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Telephone | 405-205-7424
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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