Provider Demographics
NPI:1235162199
Name:WILLIAMS, BRIAN JEFFERY (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JEFFERY
Last Name:WILLIAMS
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 1:602 FORT UNION BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-2216
Mailing Address - Country:US
Mailing Address - Phone:801-313-1010
Mailing Address - Fax:801-747-2116
Practice Address - Street 1:602 FORT UNION BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2216
Practice Address - Country:US
Practice Address - Phone:801-313-1010
Practice Address - Fax:801-747-2116
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5322538-1205207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5439OtherMEDICAID LICENSE NUMBER
UT1235162199Medicaid
UTD5439OtherMEDICAID LICENSE NUMBER
UT1235162199Medicaid