Provider Demographics
NPI:1558709352
Name:ENNISS, BRENT A (DO)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:A
Last Name:ENNISS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 744326
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4326
Mailing Address - Country:US
Mailing Address - Phone:303-695-2635
Mailing Address - Fax:303-873-5660
Practice Address - Street 1:1455 S POTOMAC ST STE 101
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4501
Practice Address - Country:US
Practice Address - Phone:303-695-2635
Practice Address - Fax:303-873-5660
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1337207ZB0001X
TXBP10048437208D00000X
CODR.0068949207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion MedicineGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty