Provider Demographics
NPI:1639150204
Name:MENMUIR, BRETT GORDON (MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:GORDON
Last Name:MENMUIR
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 1:11603 SHELDON RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-4306
Mailing Address - Country:US
Mailing Address - Phone:775-786-3040
Mailing Address - Fax:
Practice Address - Street 1:1724 33RD ST STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839
Practice Address - Country:US
Practice Address - Phone:407-385-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME134260207XS0117X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100505993Medicaid
FLH87507OtherMEDICARE UPIN
FL39576OtherMEDICARE UPIN
FL9947OtherBXBS PROVIDER #