Provider Demographics
NPI:1518981075
Name:WELLEN, MARVIN (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:WELLEN
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 1:17971 BISCAYNE BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33160-2578
Mailing Address - Country:US
Mailing Address - Phone:305-931-0555
Mailing Address - Fax:305-935-9747
Practice Address - Street 1:17971 BISCAYNE BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33160-2578
Practice Address - Country:US
Practice Address - Phone:305-931-0555
Practice Address - Fax:305-935-9747
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35679207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273134700Medicaid
FL95352Medicare PIN
FL273134700Medicaid