Provider Demographics
NPI:1174799688
Name:BRENNAN, MATTHEW PETER (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:PETER
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2104 GAUSE BLVD W
Mailing Address - Street 2:SUITE A
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460-4130
Mailing Address - Country:US
Mailing Address - Phone:985-643-4512
Mailing Address - Fax:985-643-4513
Practice Address - Street 1:624 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-2715
Practice Address - Country:US
Practice Address - Phone:228-467-9905
Practice Address - Fax:228-467-9961
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24902208D00000X
CT55111207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice