Provider Demographics
NPI:1104984343
Name:DRENNAN, KIRK BRADLEY (OD)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:BRADLEY
Last Name:DRENNAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 E WINCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7305
Mailing Address - Country:US
Mailing Address - Phone:801-263-9125
Mailing Address - Fax:801-269-1339
Practice Address - Street 1:228 E WINCHESTER ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7305
Practice Address - Country:US
Practice Address - Phone:801-263-9125
Practice Address - Fax:801-269-1339
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5147696-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU92381Medicare UPIN
UT000067554Medicare PIN