Provider Demographics
NPI:1104804038
Name:WEED, BRENT ROBERT (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:ROBERT
Last Name:WEED
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:3935 N. LIGHTNING DRIVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7890
Practice Address - Country:US
Practice Address - Phone:920-968-1790
Practice Address - Fax:920-686-9674
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51390-020207N00000X, 207ND0900X
WI51390-20207ZD0900X
MN47142207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35193300Medicaid
WIBW8392401OtherDEA
WIP00609408OtherRAILROAD MEDICARE
WI001317140OtherMEDICARE
MN408021100Medicaid
WI51390-020OtherSTATE LICENSE
WIP00609408OtherRAILROAD MEDICARE
WI001317140OtherMEDICARE
MN070000676Medicare ID - Type Unspecified