Provider Demographics
NPI:1134183080
Name:RETHERFORD, BRIAN SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:SCOTT
Last Name:RETHERFORD
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 1:17 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-9515
Mailing Address - Country:US
Mailing Address - Phone:307-359-8127
Mailing Address - Fax:
Practice Address - Street 1:111 S 5TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-2434
Practice Address - Country:US
Practice Address - Phone:307-358-7365
Practice Address - Fax:307-358-7347
Is Sole Proprietor?:No
Enumeration Date:2006-04-16
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82303207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A823030Medicaid
WYW23484Medicare PIN
CAH56825Medicare UPIN
CA00A823030Medicare ID - Type Unspecified