Healthcare Provider Details

I. General information

NPI: 1093899734
Provider Name (Legal Business Name): MARC ALAN BRENNER D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 01/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7309 MYRTLE AVE
GLENDALE NY
11385-7431
US

IV. Provider business mailing address

7309 MYRTLE AVE
GLENDALE NY
11385-7431
US

V. Phone/Fax

Practice location:
  • Phone: 718-456-7270
  • Fax: 718-456-1874
Mailing address:
  • Phone: 718-456-7270
  • Fax: 718-456-1874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN002371-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: