Provider Demographics
NPI:1063400620
Name:BRENNAN, THERESA MARIE (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:MARIE
Other - Last Name:HERBST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-1607
Mailing Address - Fax:319-356-4552
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-1607
Practice Address - Fax:319-356-4552
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA30434207R00000X, 207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA52299OtherWELLMARK BCBS
IA0130765Medicaid
G16684Medicare UPIN
IA52299OtherWELLMARK BCBS