Provider Demographics
NPI:1366934879
Name:RENNAKER, MAXWELL EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:MAXWELL
Middle Name:EDWARD
Last Name:RENNAKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3736 PRAIRIE ST SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1634
Mailing Address - Country:US
Mailing Address - Phone:616-648-8456
Mailing Address - Fax:
Practice Address - Street 1:2700 5 MILE RD NE STE 102
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6516
Practice Address - Country:US
Practice Address - Phone:330-908-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.006660152W00000X
MI4901005238152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist