Healthcare Provider Details

I. General information

NPI: 1457312662
Provider Name (Legal Business Name): BRIAN LEE WHITED MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 MILL ST W
CANNON FALLS MN
55009-1824
US

IV. Provider business mailing address

1116 MILL ST W
CANNON FALLS MN
55009-1824
US

V. Phone/Fax

Practice location:
  • Phone: 507-293-3951
  • Fax:
Mailing address:
  • Phone: 507-263-3951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35878
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: