Provider Demographics
NPI:1063565075
Name:BRENNER, ALAN STEVEN (MD)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:STEVEN
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 1:201 CEDAR ST SE
Mailing Address - Street 2:SUITE 4600
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4917
Mailing Address - Country:US
Mailing Address - Phone:505-563-6450
Mailing Address - Fax:505-563-6484
Practice Address - Street 1:201 CEDAR ST SE
Practice Address - Street 2:SUITE 4600
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4917
Practice Address - Country:US
Practice Address - Phone:505-563-6450
Practice Address - Fax:505-563-6484
Is Sole Proprietor?:No
Enumeration Date:2007-01-21
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016472207YX0905X
SD8123207YX0905X
NMMD2012-0882207YX0905X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1158609Medicaid
WAG000100601OtherMEDICARE
SD6301580Medicaid
WAG000100601OtherMEDICARE
WA0100601Medicare ID - Type Unspecified
WAA04135Medicare UPIN