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General NPI Number Information
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NPI Number | 1942850078
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Entity Type | Individual
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Provider Name | PAUL-ROBERT DERENONCOURT MD
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Gender | Male
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Dates
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Enumeration Date | 09/20/2019
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Last Update Date | 12/12/2024
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Provider Practice Location Address
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Address Line | 1120 15TH ST
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City | AUGUSTA
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State | GA
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Zip | 30912-1016
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Country | US
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Telephone | 706-721-8623
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Fax |
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Provider Business Mailing Address
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Address Line | 1013 WESLEYAN CIR
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City | EVANS
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State | GA
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Zip | 30809-0227
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Country | US
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Telephone | 314-760-4443
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207U00000X
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Taxonomy Name | Nuclear Medicine Physician
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License Number | 96592
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 96592
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License Number State | GA
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