Provider Demographics
NPI:1437330446
Name:ROBERT M. BRENNER O.D.
Entity Type:Organization
Organization Name:ROBERT M. BRENNER O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRENNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-525-0030
Mailing Address - Street 1:70 PARK AVE W
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44902-1624
Mailing Address - Country:US
Mailing Address - Phone:419-525-1207
Mailing Address - Fax:419-525-0030
Practice Address - Street 1:70 PARK AVE W
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44902-1624
Practice Address - Country:US
Practice Address - Phone:419-525-1207
Practice Address - Fax:419-525-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3398332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2036255Medicaid
OH0200520001Medicare NSC
OHT47091Medicare UPIN
OH2036255Medicaid