Provider Demographics
NPI:1467613711
Name:WELLS, CASEY A (OD)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:A
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 1:219 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-4327
Mailing Address - Country:US
Mailing Address - Phone:870-236-7713
Mailing Address - Fax:870-236-7713
Practice Address - Street 1:219 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450
Practice Address - Country:US
Practice Address - Phone:870-236-7713
Practice Address - Fax:870-236-7713
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008017057152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR168700722Medicaid