Provider Demographics
NPI:1407841158
Name:WELLS, MARK T (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:WELLS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3230
Mailing Address - Country:US
Mailing Address - Phone:307-638-6610
Mailing Address - Fax:307-638-6451
Practice Address - Street 1:1200 E PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3230
Practice Address - Country:US
Practice Address - Phone:307-638-6610
Practice Address - Fax:307-638-6451
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY196T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY0959310001Medicare NSC
WYCS9631Medicare ID - Type UnspecifiedRAILROAD GROUP NUMBER
WYU18535Medicare UPIN