Provider Demographics
NPI:1659372019
Name:WRENN, JOHN JEFFRIES (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JEFFRIES
Last Name:WRENN
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 1:509 N ELAM AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-1157
Mailing Address - Country:US
Mailing Address - Phone:336-274-1114
Mailing Address - Fax:336-232-5325
Practice Address - Street 1:509 N ELAM AVE FL 2
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1157
Practice Address - Country:US
Practice Address - Phone:336-274-1114
Practice Address - Fax:336-232-5325
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33325208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89277OtherBLUE CROSS CLUE SHIELD NC
NC8989277Medicaid
NC2147044GMedicare PIN
NC89277OtherBLUE CROSS CLUE SHIELD NC
340017965Medicare PIN
NC2147044FMedicare PIN
NC8989277Medicaid
NCE39275Medicare UPIN