Provider Demographics
NPI:1417966409
Name:BRENTJENS, MATHIJS HENRI (MD)
Entity Type:Individual
Prefix:DR
First Name:MATHIJS
Middle Name:HENRI
Last Name:BRENTJENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:420 SPRING FOREST RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7244
Mailing Address - Country:US
Mailing Address - Phone:252-752-4124
Mailing Address - Fax:252-758-8954
Practice Address - Street 1:222 VIRGINIA RD
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-9667
Practice Address - Country:US
Practice Address - Phone:252-752-4124
Practice Address - Fax:252-758-8954
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200500012207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00234813OtherRAILROAD MEDICARE
NC5902501Medicaid
NC140T2OtherBLUE CROSS BLUE SHIELD NC
NC8899677OtherCIGNA HEALTLHCARE NC
NC5902501Medicaid
NCI37404Medicare UPIN