Provider Demographics
NPI:1497714273
Name:WELLER, KATHRIN ANNETTE (MD)
Entity Type:Individual
Prefix:
First Name:KATHRIN
Middle Name:ANNETTE
Last Name:WELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:K.
Other - Middle Name:ANNETTE
Other - Last Name:WELLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:242 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401
Mailing Address - Country:US
Mailing Address - Phone:541-683-4242
Mailing Address - Fax:541-343-5078
Practice Address - Street 1:242 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2477
Practice Address - Country:US
Practice Address - Phone:541-683-4242
Practice Address - Fax:541-343-5078
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR055512Medicaid
OR055512Medicaid
00WCHCGHMedicare ID - Type Unspecified