Provider Demographics
NPI:1467681395
Name:WELLS, THAD DUSTIN (OD)
Entity Type:Individual
Prefix:DR
First Name:THAD
Middle Name:DUSTIN
Last Name:WELLS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:105 ROBINS WAY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-1129
Mailing Address - Country:US
Mailing Address - Phone:270-726-2022
Mailing Address - Fax:270-726-2035
Practice Address - Street 1:105 ROBINS WAY
Practice Address - Street 2:SUITE 206
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-1129
Practice Address - Country:US
Practice Address - Phone:270-726-2022
Practice Address - Fax:270-726-2035
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1770DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100085750Medicaid
01076001Medicare UPIN