Provider Demographics
NPI:1346405602
Name:BRICKNER, DEREK M (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:M
Last Name:BRICKNER
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 1:300 2ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-3373
Mailing Address - Country:US
Mailing Address - Phone:701-251-6000
Mailing Address - Fax:
Practice Address - Street 1:300 2ND AVE NE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-3373
Practice Address - Country:US
Practice Address - Phone:701-251-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NETEP5877207Q00000X
ND11895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16213Medicaid
NE47055301100Medicaid
NDN718693Medicare PIN