Healthcare Provider Details

I. General information

NPI: 1801858048
Provider Name (Legal Business Name): MARK IAN BRENIS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 PENNY LN SUITE 1
WATSONVILLE CA
95076-6055
US

IV. Provider business mailing address

47 PENNY LN SUITE 1
WATSONVILLE CA
95076-6055
US

V. Phone/Fax

Practice location:
  • Phone: 831-728-8844
  • Fax: 831-763-1001
Mailing address:
  • Phone: 831-728-8844
  • Fax: 831-763-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE3289
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberE3289
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberE3289
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberE3289
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: