Provider Demographics
NPI:1033143482
Name:BRENES, RYAN BENJAMIN (DO)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:BENJAMIN
Last Name:BRENES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 182
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32004-0182
Mailing Address - Country:US
Mailing Address - Phone:306-619-5517
Mailing Address - Fax:
Practice Address - Street 1:820 PRUDENTIAL DR
Practice Address - Street 2:SUITE 713
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8210
Practice Address - Country:US
Practice Address - Phone:306-619-5517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2014-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10346207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLVAD0000Medicare UPIN