Basic Information
| Provider Information | |||||||||
| NPI: | 1134236888 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRENNESSEL | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 BIRCHELL LN | ||||||||
| Address2: | |||||||||
| City: | GLEN HEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115452214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166743218 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8268 164TH ST | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114321121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188834847 | ||||||||
| FaxNumber: | 7188836197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 03/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 144468 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 144468 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | BB0244816 | 01 | NY | DEA | OTHER | 01089005 | 05 | NY | MEDICAID |