Provider Demographics
NPI:1275680076
Name:REAGAN, BRENDAN W (MD)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:W
Last Name:REAGAN
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 1:1300 W TERRELL AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2820
Mailing Address - Country:US
Mailing Address - Phone:817-252-5000
Mailing Address - Fax:
Practice Address - Street 1:1300 W TERRELL AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2820
Practice Address - Country:US
Practice Address - Phone:817-252-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN42929207R00000X
TXP2158207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
0009880173OtherAETNA
TX305771301Medicaid
TN1506020Medicaid
KY7100051780OtherKENTUCKY MEDICAID
TN4190818OtherBCBST
3001892Medicare PIN
KY7100051780OtherKENTUCKY MEDICAID