Provider Demographics
NPI:1710075403
Name:BRENNAN, MARY C (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:BRENNAN
Suffix:
Gender:F
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:6210 JOHN RYAN DR
Practice Address - Street 2:STE 101
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4113
Practice Address - Country:US
Practice Address - Phone:817-370-0840
Practice Address - Fax:817-370-1590
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5846208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8938220OtherCIGNA PIN
TXBREME37342OtherCCHIP PIN
TX140910101OtherFIRSTCARE PIN
TX111736804Medicaid
TX00U87ZOtherBCBSTX GRP PIN
TX4525795OtherAETNA PIN
TX869827OtherUHC PIN
TX111736805OtherCSHCN
1750369203OtherGRP NPI NUMBER
TX89W002OtherBCBSTX IND PIN
TX1336743OtherFIRSTHEALTH PIN
TX139481OtherPHCS PIN
1750369203OtherGRP NPI NUMBER
TX8938220OtherCIGNA PIN