Provider Demographics
NPI:1043214901
Name:BRENNER, BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:BRENNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12554 RIATA VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-6431
Mailing Address - Country:US
Mailing Address - Phone:512-795-5100
Mailing Address - Fax:512-795-5122
Practice Address - Street 1:12554 RIATA VISTA CIR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-6431
Practice Address - Country:US
Practice Address - Phone:512-795-5100
Practice Address - Fax:512-795-5122
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL21522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00282122OtherRRMCARE2
TX146838102OtherCSCHN1
P00145598OtherRRMCARE
TX146838103OtherCSHCN2
TX146838102Medicaid
TX146838103Medicaid
P00145598OtherRRMCARE
TX146838103Medicaid
P00282122OtherRRMCARE2