Provider Demographics
NPI:1083612238
Name:WELLS, JED M (DPM)
Entity Type:Individual
Prefix:
First Name:JED
Middle Name:M
Last Name:WELLS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60998
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-0998
Mailing Address - Country:US
Mailing Address - Phone:361-452-4978
Mailing Address - Fax:361-452-5026
Practice Address - Street 1:6828 SPRINGFIELD AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-2286
Practice Address - Country:US
Practice Address - Phone:956-726-9797
Practice Address - Fax:956-726-9965
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2015-06-11
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
TXTX1355213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092738602Medicaid
TXU32769Medicare UPIN
TX00205EMedicare ID - Type UnspecifiedPROVIDER NUMBER