Provider Demographics
NPI:1205011863
Name:JOHN PATRICK BRENNAN OD PA
Entity Type:Organization
Organization Name:JOHN PATRICK BRENNAN OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:BRENNAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:OD PA
Authorized Official - Phone:863-467-0595
Mailing Address - Street 1:710 S PARROTT AVE
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974-5138
Mailing Address - Country:US
Mailing Address - Phone:863-467-0595
Mailing Address - Fax:863-467-1686
Practice Address - Street 1:710 S PARROTT AVE
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34974-5138
Practice Address - Country:US
Practice Address - Phone:863-467-0595
Practice Address - Fax:863-467-1686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFLOPC971152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084047500Medicaid
FL19044OtherBLUE CROSS BLUE SHIELD
FL084047500Medicaid
FL0536130001Medicare NSC