Provider Demographics
NPI:1437254075
Name:BRENNER, ROBERT A (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:BRENNER
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:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-339-5421
Mailing Address - Fax:
Practice Address - Street 1:3927 RUCKER AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4833
Practice Address - Country:US
Practice Address - Phone:425-339-5421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60625350207RG0100X
TXQ3152207RG0100X
CAG51139207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G511390Medicaid
CAWG51139AMedicare PIN
CA00G511390Medicaid
CAWG51139AMedicare PIN