Provider Demographics
NPI:1508803768
Name:BRENNER, FRED J (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:J
Last Name:BRENNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:94-300 FARRINGTON HWY
Mailing Address - Street 2:SUITE F8
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-2699
Mailing Address - Country:US
Mailing Address - Phone:808-677-1433
Mailing Address - Fax:808-677-1676
Practice Address - Street 1:94-300 FARRINGTON HWY
Practice Address - Street 2:SUITE F8
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-2699
Practice Address - Country:US
Practice Address - Phone:808-677-1433
Practice Address - Fax:808-677-1676
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2017-02-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA61240207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A612400OtherCALOPTIMA
CA050126CF71733OtherVALLEY PRES TRAILBLAZER
CA00A612402Medicare ID - Type UnspecifiedDELANO REG MED CENTER
CAF71733Medicare UPIN
CAWA61240AMedicare Oscar/Certification
CA00A612400OtherBLUE SHIELD
CAA61240OtherBLUE CROSS
CA00A612401Medicare Oscar/Certification
CA050618CF71733OtherBEAR VALLEY TRAILBLAZER
CA00A612400Medicaid