Provider Demographics
NPI:1386658730
Name:WELLS, ERIC DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:DONALD
Last Name:WELLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ERIC
Other - Middle Name:DONALD
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:20055 LAKE CHABOT RD
Mailing Address - Street 2:#320
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546
Mailing Address - Country:US
Mailing Address - Phone:510-889-8900
Mailing Address - Fax:510-727-9811
Practice Address - Street 1:20055 LAKE CHABOT RD
Practice Address - Street 2:#320
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546
Practice Address - Country:US
Practice Address - Phone:510-889-8900
Practice Address - Fax:510-727-9811
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51925208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G519250Medicaid