Provider Demographics
NPI:1487664496
Name:O'HARA, BRENDA (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:O'HARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:S
Other - Last Name:O'HARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8911 LIBERTY MILLS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6311
Practice Address - Country:US
Practice Address - Phone:260-373-9465
Practice Address - Fax:260-266-9406
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036208A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100082420AMedicaid
IN069860A3Medicare PIN
IN259060BBMedicare PIN
INE64683Medicare UPIN
IN100082420AMedicaid