Provider Demographics
NPI:1497763940
Name:WELLENSTEIN, DAVID EARL (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EARL
Last Name:WELLENSTEIN
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 1:185 GENESEE ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-2199
Mailing Address - Country:US
Mailing Address - Phone:315-793-8806
Mailing Address - Fax:315-793-8046
Practice Address - Street 1:185 GENESEE ST
Practice Address - Street 2:SUITE 600
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-2199
Practice Address - Country:US
Practice Address - Phone:315-793-8806
Practice Address - Fax:315-793-8046
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1326172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY300029077OtherRAIL ROAD MEDICARE
NY225159OtherMVP
NY00751524Medicaid
NYP010149411OtherBC/BS
NY10043865OtherCDPHP
NY4102251OtherGHI
NY040426013871OtherFIDELIS
NYB81948Medicare UPIN
NY300029077OtherRAIL ROAD MEDICARE
300029077Medicare PIN