Provider Demographics
NPI:1629043625
Name:DRENNAN, PETER JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOHN
Last Name:DRENNAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104
Mailing Address - Country:US
Mailing Address - Phone:413-739-5676
Mailing Address - Fax:413-733-5860
Practice Address - Street 1:701 ENFIELD STREET
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:860-741-6058
Practice Address - Fax:860-253-9326
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT64560207R00000X
MA54104207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110051774AMedicaid
CT003116242Medicaid
MA64994127Medicaid
110197249Medicare PIN
MAF35774Medicare UPIN