Provider Demographics
NPI:1730188764
Name:BRENNER, STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:BRENNER
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 1:2989 DIXWELL AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3501
Mailing Address - Country:US
Mailing Address - Phone:203-248-3013
Mailing Address - Fax:203-248-2878
Practice Address - Street 1:129 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5608
Practice Address - Country:US
Practice Address - Phone:203-789-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT17408207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010017408CT03OtherBLUE CROSS BLUE SHIELD
CTNHP118OtherOXFORD
CT1051333OtherAETNA
CT757491OtherCONNECTICARE
CT110009425Medicare ID - Type Unspecified
CT1051333OtherAETNA