Provider Demographics
NPI:1255952651
Name:DECENSO, BRENDAN MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:MICHAEL
Last Name:DECENSO
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 1:10537 ADVENTURE LN
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45242-4903
Mailing Address - Country:US
Mailing Address - Phone:513-885-9135
Mailing Address - Fax:
Practice Address - Street 1:170 MANNING DR # 7594
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4221
Practice Address - Country:US
Practice Address - Phone:513-885-9135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261306390200000X
NC2022-02039207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program