Provider Demographics
NPI:1710125893
Name:WILLIAMS, BRENT RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:RICHARD
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 1:2422 20TH ST SW
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401
Mailing Address - Country:US
Mailing Address - Phone:330-671-7783
Mailing Address - Fax:701-952-4564
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-2301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-28
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.007614208800000X
ND11253208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10698Medicaid
ND10698Medicaid