Provider Demographics
NPI:1467437624
Name:WELLS, KENNETH (DPM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WELLS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 EUCLID AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-3610
Mailing Address - Country:US
Mailing Address - Phone:619-527-0051
Mailing Address - Fax:619-527-0056
Practice Address - Street 1:286 EUCLID AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-3610
Practice Address - Country:US
Practice Address - Phone:619-527-0051
Practice Address - Fax:619-527-0056
Is Sole Proprietor?:No
Enumeration Date:2005-12-10
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3455213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E34550Medicaid
CA4728380001Medicare NSC
CA000E34550Medicaid
CAE3455Medicare PIN