Provider Demographics
NPI:1427023043
Name:BRENZIE, MARK A (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:BRENZIE
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4099 BASSWOOD RD
Mailing Address - Street 2:
Mailing Address - City:DISPUTANTA
Mailing Address - State:VA
Mailing Address - Zip Code:23842-4517
Mailing Address - Country:US
Mailing Address - Phone:804-898-1850
Mailing Address - Fax:
Practice Address - Street 1:411 W RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2938
Practice Address - Country:US
Practice Address - Phone:804-414-0312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012385832083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010211247Medicaid
008436P95 - C03895Medicare ID - Type Unspecified
VA010211247Medicaid