Provider Demographics
NPI:1083146468
Name:WELLMAN, TYLER (MD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:WELLMAN
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 1:2712 AUGUSTINE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95054-2941
Mailing Address - Country:US
Mailing Address - Phone:408-780-2542
Mailing Address - Fax:
Practice Address - Street 1:2712 AUGUSTINE DR STE 120
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95054-2941
Practice Address - Country:US
Practice Address - Phone:408-780-2542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA16997352083A0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine