Provider Demographics
NPI:1215100383
Name:BRENNER, RICHARD WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:WILLIAM
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:PO BOX 5095
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94977-5095
Mailing Address - Country:US
Mailing Address - Phone:415-927-2765
Mailing Address - Fax:415-461-4626
Practice Address - Street 1:980 MAGNOLIA AVE
Practice Address - Street 2:STE 8
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939
Practice Address - Country:US
Practice Address - Phone:415-927-2767
Practice Address - Fax:415-461-4626
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87962084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE24899Medicare UPIN