Provider Demographics
NPI:1033287347
Name:BRENNER, JACK LEON (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:LEON
Last Name:BRENNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:L
Other - Last Name:BRENNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1974 MAPLE HILL ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-4190
Mailing Address - Country:US
Mailing Address - Phone:914-962-5596
Mailing Address - Fax:914-962-5919
Practice Address - Street 1:1974 MAPLE HILL STREET
Practice Address - Street 2:SUITE 6
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598
Practice Address - Country:US
Practice Address - Phone:914-962-5596
Practice Address - Fax:914-962-5919
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106478207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C11424Medicare UPIN
NY566821Medicare ID - Type Unspecified