Provider Demographics
NPI:1518949049
Name:WELLER, MICHAEL H (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:WELLER
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 1:3 FLYING MANE RD
Mailing Address - Street 2:
Mailing Address - City:ROLLING HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90274-5238
Mailing Address - Country:US
Mailing Address - Phone:310-541-7871
Mailing Address - Fax:
Practice Address - Street 1:2801 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806
Practice Address - Country:US
Practice Address - Phone:562-933-1550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG124972085P0229X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G124970OtherMEDICAL
CA00G124970OtherMEDICAL