Provider Demographics
NPI:1093851610
Name:WELLS, MARY MELINDA (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:MELINDA
Last Name:WELLS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:23591 EL TORO ROAD
Mailing Address - Street 2:STE 145
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630
Mailing Address - Country:US
Mailing Address - Phone:949-859-3180
Mailing Address - Fax:949-859-6317
Practice Address - Street 1:23591 EL TORO ROAD
Practice Address - Street 2:STE 145
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630
Practice Address - Country:US
Practice Address - Phone:949-859-3180
Practice Address - Fax:949-859-6317
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0P9120T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8566227Medicaid
CA8566227Medicaid
U18495Medicare UPIN