Provider Demographics
NPI:1912276643
Name:MARC A. BRENNER, D.P.M., PLLC
Entity Type:Organization
Organization Name:MARC A. BRENNER, D.P.M., PLLC
Other - Org Name:MARC ALAN BRENNER D.P.M., PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHARESE
Authorized Official - Middle Name:
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-573-1123
Mailing Address - Street 1:83 WHEATLEY RD
Mailing Address - Street 2:
Mailing Address - City:OLD WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11568-1210
Mailing Address - Country:US
Mailing Address - Phone:516-355-2277
Mailing Address - Fax:516-626-9243
Practice Address - Street 1:2001 MARCUS AVENUE
Practice Address - Street 2:
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042
Practice Address - Country:US
Practice Address - Phone:516-355-2277
Practice Address - Fax:516-626-9243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-27
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN002371-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty