Provider Demographics
NPI:1487652087
Name:WELLS, WILLIAM R (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
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 1:510 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IN
Mailing Address - Zip Code:47670-1406
Mailing Address - Country:US
Mailing Address - Phone:812-386-7001
Mailing Address - Fax:812-386-3952
Practice Address - Street 1:510 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IN
Practice Address - Zip Code:47670-1406
Practice Address - Country:US
Practice Address - Phone:812-386-7001
Practice Address - Fax:812-386-3952
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01017790207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100121930Medicaid
IN940920A6Medicare ID - Type Unspecified
IN100121930Medicaid