Provider Demographics
NPI:1457302630
Name:WELLER, JEFFREY C (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
Last Name:WELLER
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:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-0146
Mailing Address - Country:US
Mailing Address - Phone:360-417-7111
Mailing Address - Fax:360-417-7342
Practice Address - Street 1:303 W 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362
Practice Address - Country:US
Practice Address - Phone:360-457-8578
Practice Address - Fax:360-457-4841
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037703208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8256521Medicaid