Provider Demographics
NPI:1467590703
Name:BRENES, JOSEPH A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:A
Last Name:BRENES
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 1:464 WOLCOTT RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-2626
Mailing Address - Country:US
Mailing Address - Phone:203-879-8003
Mailing Address - Fax:203-879-8010
Practice Address - Street 1:464 WOLCOTT RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-2626
Practice Address - Country:US
Practice Address - Phone:203-879-8003
Practice Address - Fax:203-879-8010
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT019732207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001197326Medicaid
CT001197326Medicaid
CTB84082Medicare UPIN