Provider Demographics
NPI:1801858048
Name:BRENIS, MARK IAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:IAN
Last Name:BRENIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:47 PENNY LN
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-6055
Mailing Address - Country:US
Mailing Address - Phone:831-728-8844
Mailing Address - Fax:831-763-1001
Practice Address - Street 1:47 PENNY LN
Practice Address - Street 2:SUITE 1
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-6055
Practice Address - Country:US
Practice Address - Phone:831-728-8844
Practice Address - Fax:831-763-1001
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3289213E00000X, 213EP1101X, 213ES0000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT11613Medicare UPIN
CA4168780001Medicare NSC