Healthcare Provider Details

I. General information

NPI: 1003852815
Provider Name (Legal Business Name): LOUIS BRENNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 ALTA AVE SUITE 110
UPLAND CA
91786-2800
US

IV. Provider business mailing address

1113 ALTA AVE SUITE 110
UPLAND CA
91786-2800
US

V. Phone/Fax

Practice location:
  • Phone: 909-949-8000
  • Fax: 909-920-1111
Mailing address:
  • Phone: 909-949-8000
  • Fax: 909-920-1111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG36509
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: