Provider Demographics
NPI:1629058615
Name:BRENEISEN, JEFFREY R (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:BRENEISEN
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 1:1860 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3590
Mailing Address - Country:US
Mailing Address - Phone:707-646-4400
Mailing Address - Fax:707-646-4401
Practice Address - Street 1:1860 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3590
Practice Address - Country:US
Practice Address - Phone:707-646-4400
Practice Address - Fax:707-646-4401
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86677207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G866770Medicaid
CAH94902Medicare UPIN
CA00G866770Medicaid