Provider Demographics
NPI:1073523064
Name:WELLS, E. ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:E.
Middle Name:ROBERT
Last Name:WELLS
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 1:10101 SE MAIN ST
Mailing Address - Street 2:SUITE 3008
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2455
Mailing Address - Country:US
Mailing Address - Phone:503-253-1223
Mailing Address - Fax:503-253-1530
Practice Address - Street 1:10101 SE MAIN ST
Practice Address - Street 2:SUITE 3008
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2455
Practice Address - Country:US
Practice Address - Phone:503-253-1223
Practice Address - Fax:503-253-1530
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08649174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213397Medicaid
ORR0000BHDNZMedicare ID - Type Unspecified
ORC94556Medicare UPIN