Provider Demographics
NPI:1790797199
Name:FLETCHER, BRENT P (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:P
Last Name:FLETCHER
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 1:2031 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-5181
Mailing Address - Country:US
Mailing Address - Phone:715-423-0122
Mailing Address - Fax:
Practice Address - Street 1:2031 PEACH ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-5181
Practice Address - Country:US
Practice Address - Phone:715-423-0122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41790207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32613200Medicaid
WIA56369Medicare UPIN
WI32613200Medicaid