Provider Demographics
NPI:1043282767
Name:BRENNAN, FRED H JR (DO)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:H
Last Name:BRENNAN
Suffix:JR
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 1:807 N MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755-4254
Mailing Address - Country:US
Mailing Address - Phone:727-467-2400
Mailing Address - Fax:727-467-2477
Practice Address - Street 1:807 N MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33755-4254
Practice Address - Country:US
Practice Address - Phone:727-467-2400
Practice Address - Fax:727-467-2477
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13446207Q00000X, 207QS0010X
VA0102201136207QS0010X
ME2066207QS0010X
FLOS14442207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30225211Medicaid
FL021438100Medicaid
ME432690199Medicaid
NH000192001Medicare PIN
FL021438100Medicaid
NHG30138Medicare UPIN