Healthcare Provider Details

I. General information

NPI: 1033287347
Provider Name (Legal Business Name): JACK LEON BRENNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JACK L. BRENNER MD

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1974 MAPLE HILL STREET SUITE 6
YORKTOWN HEIGHTS NY
10598
US

IV. Provider business mailing address

1974 MAPLE HILL ST SUITE 6
YORKTOWN HEIGHTS NY
10598-4190
US

V. Phone/Fax

Practice location:
  • Phone: 914-962-5596
  • Fax: 914-962-5919
Mailing address:
  • Phone: 914-962-5596
  • Fax: 914-962-5919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number106478
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number106478
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: