Provider Demographics
NPI:1255502050
Name:BRIAN J WILLIAMS MD PC
Entity Type:Organization
Organization Name:BRIAN J WILLIAMS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JEFFERY
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-313-1010
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5322538-1205207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5439OtherMEDICAID LICENSE NUMBER
UT1235162199Medicaid
UTD5439OtherMEDICAID LICENSE NUMBER
UT1235162199Medicaid