Provider Demographics
NPI:1457312662
Name:WHITED, BRIAN LEE (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEE
Last Name:WHITED
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 1:1116 MILL ST W
Mailing Address - Street 2:
Mailing Address - City:CANNON FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:55009-1824
Mailing Address - Country:US
Mailing Address - Phone:507-263-3951
Mailing Address - Fax:
Practice Address - Street 1:1116 MILL ST W
Practice Address - Street 2:
Practice Address - City:CANNON FALLS
Practice Address - State:MN
Practice Address - Zip Code:55009-1824
Practice Address - Country:US
Practice Address - Phone:507-293-3951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35878207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN043368300Medicaid
MN043368300Medicaid
080005144Medicare ID - Type Unspecified