Provider Demographics
NPI:1013927797
Name:BRENNAN, BRUCE T (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:T
Last Name:BRENNAN
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 1:22 WESTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ANSONIA
Mailing Address - State:CT
Mailing Address - Zip Code:06401-1158
Mailing Address - Country:US
Mailing Address - Phone:203-734-7100
Mailing Address - Fax:203-734-3392
Practice Address - Street 1:22 WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-1158
Practice Address - Country:US
Practice Address - Phone:203-734-7100
Practice Address - Fax:203-734-3392
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022798207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1227982Medicaid
CT110001040Medicare ID - Type Unspecified
CT1227982Medicaid