Provider Demographics
NPI:1407863459
Name:WELLS, STANLEY DALE (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:DALE
Last Name:WELLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 TIERRA BELLA DR
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-9673
Mailing Address - Country:US
Mailing Address - Phone:316-734-2502
Mailing Address - Fax:
Practice Address - Street 1:416 TIERRA BELLA DR
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-9673
Practice Address - Country:US
Practice Address - Phone:316-734-2502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2003-02572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM98338731Medicaid