Provider Demographics
NPI:1508871450
Name:TICHENOR, WELLINGTON SHELTON (MD)
Entity Type:Individual
Prefix:DR
First Name:WELLINGTON
Middle Name:SHELTON
Last Name:TICHENOR
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 1:642 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-6105
Mailing Address - Country:US
Mailing Address - Phone:212-517-6611
Mailing Address - Fax:212-517-2132
Practice Address - Street 1:642 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-6105
Practice Address - Country:US
Practice Address - Phone:212-517-6611
Practice Address - Fax:212-517-2132
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY127559207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB00097Medicare UPIN