Provider Demographics
NPI:1306894753
Name:BRENNER, LAURENCE HARVEY (MD)
Entity type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:HARVEY
Last Name:BRENNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LAURENCE
Other - Middle Name:H
Other - Last Name:BRENNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD PA
Mailing Address - Street 1:232 CYPRESS HILLS WAY
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-7352
Mailing Address - Country:US
Mailing Address - Phone:407-489-8524
Mailing Address - Fax:386-624-6297
Practice Address - Street 1:3030 HARDEN BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-7952
Practice Address - Country:US
Practice Address - Phone:863-687-1250
Practice Address - Fax:863-687-1258
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2022-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91864174400000X, 2086S0122X, 2086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No174400000XOther Service ProvidersSpecialist
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7473OtherMEDICARE GROUP PROVIDER
FL274526700Medicaid
FL52154AOtherMEDICARE PROVIDER
FL6137800001OtherMEDICARE NSC
FL6137800001OtherMEDICARE NSC
52154ZMedicare PIN