Provider Demographics
NPI:1114909579
Name:WELLS, MICHAEL B (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:WELLS
Suffix:
Gender:M
Credentials:DO
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 347
Mailing Address - Street 2:250 S MAIN ST
Mailing Address - City:EUREKA
Mailing Address - State:NV
Mailing Address - Zip Code:89316-0347
Mailing Address - Country:US
Mailing Address - Phone:775-237-5313
Mailing Address - Fax:775-237-5073
Practice Address - Street 1:250 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:NV
Practice Address - Zip Code:89316-0347
Practice Address - Country:US
Practice Address - Phone:775-237-5313
Practice Address - Fax:775-237-5073
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013720207Q00000X
IDO-0437207Q00000X
NVDO1828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4782352Medicaid
MI0P21760Medicare ID - Type Unspecified
MIH88554Medicare UPIN