Provider Demographics
NPI:1538103346
Name:BRENNER, JOEL S (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:S
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 1:601 CHILDRENS LN
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1910
Mailing Address - Country:US
Mailing Address - Phone:757-668-7475
Mailing Address - Fax:757-668-8658
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-7850
Practice Address - Fax:757-668-7885
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052850208000000X, 2080A0000X, 2080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010253977Medicaid
VA009881C38Medicare ID - Type Unspecified
G47218Medicare UPIN