Provider Demographics
NPI:1689629206
Name:BRENNER, ROBERT MAURICE (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MAURICE
Last Name:BRENNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 PARK AVE WEST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44902
Mailing Address - Country:US
Mailing Address - Phone:419-525-1207
Mailing Address - Fax:419-525-0030
Practice Address - Street 1:70 PARK AVE W
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44902-1624
Practice Address - Country:US
Practice Address - Phone:419-525-1207
Practice Address - Fax:419-525-0030
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3398152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0406742Medicaid
T47091Medicare UPIN
OH0406742Medicaid
OH0200520001Medicare NSC