Provider Demographics
NPI:1750390456
Name:BRENNER, MARK (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BRENNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 E. BANNER GATEWAY DRIVE
Mailing Address - Street 2:SUITE #450
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234
Mailing Address - Country:US
Mailing Address - Phone:480-256-6444
Mailing Address - Fax:480-256-4734
Practice Address - Street 1:2946 E BANNER GATEWAY DRIVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234
Practice Address - Country:US
Practice Address - Phone:480-256-6444
Practice Address - Fax:480-256-4734
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2207208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ258914Medicaid
AZ4316747OtherAETNA
AZAZ0063470OtherBLUECROSSBLUESHIELDAZ
AZ1Z0539OtherHEALTHNET
AZ4316747OtherAETNA
AZC98164Medicare UPIN
AZWCGDV02Medicare ID - Type Unspecified