Basic Information
| Provider Information | |||||||||
| NPI: | 1750390456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRENNER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2940 E. BANNER GATEWAY DRIVE | ||||||||
| Address2: | SUITE #450 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802566444 | ||||||||
| FaxNumber: | 4802564734 | ||||||||
| Practice Location | |||||||||
| Address1: | 2946 E BANNER GATEWAY DRIVE | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802566444 | ||||||||
| FaxNumber: | 4802564734 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 05/18/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 2207 | AZ | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 258914 | 05 | AZ | MEDICAID | 4316747 | 01 | AZ | AETNA | OTHER | AZ0063470 | 01 | AZ | BLUECROSSBLUESHIELDAZ | OTHER | 1Z0539 | 01 | AZ | HEALTHNET | OTHER |