Provider Demographics
NPI:1275845497
Name:WEBSTER, BRYAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:WEBSTER
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 1:251 E COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9619
Mailing Address - Country:US
Mailing Address - Phone:608-824-4000
Mailing Address - Fax:608-824-4917
Practice Address - Street 1:251 E COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:WI
Practice Address - Zip Code:53527-9619
Practice Address - Country:US
Practice Address - Phone:608-839-3515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI56729-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1275845497Medicaid
WI1275845497Medicaid
WIP01443014Medicare PIN