Provider Demographics
NPI:1013205871
Name:BRENNER, BENJAMIN DEAN (OD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:DEAN
Last Name:BRENNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6625 LYNDALE AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2491
Mailing Address - Country:US
Mailing Address - Phone:612-243-8999
Mailing Address - Fax:612-869-3473
Practice Address - Street 1:6625 LYNDALE AVE S STE 300
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2491
Practice Address - Country:US
Practice Address - Phone:612-243-8999
Practice Address - Fax:612-869-3473
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3766152W00000X
TN2982152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1013205871Medicaid
KY8809OtherGROUP MEDICARE PIN PTAN FOR WHITLEY
TN103I419540OtherMEDICARE PTAN
KY0966OtherGROUP MEDICARE PIN PTAN FOR ALBANY
KY2416OtherGROUP MEDICARE PIN PTAN FOR SOMERSET
KY8351OtherGROUP MEDICARE PIN PTAN FOR WILLIAMSBURG
KY2416OtherGROUP MEDICARE PIN PTAN FOR SOMERSET
KY8351OtherGROUP MEDICARE PIN PTAN FOR WILLIAMSBURG
KYK009923Medicare PIN
KY8809OtherGROUP MEDICARE PIN PTAN FOR WHITLEY
KYK009920Medicare PIN
KYK009921Medicare PIN