Provider Demographics
NPI:1548232994
Name:WELLS, CARLTON L (PA)
Entity Type:Individual
Prefix:
First Name:CARLTON
Middle Name:L
Last Name:WELLS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 LITTLE NECK RD, 3300 SOUTH BLDG
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452
Mailing Address - Country:US
Mailing Address - Phone:757-470-5570
Mailing Address - Fax:757-227-3377
Practice Address - Street 1:3300 SOUTH BLDG
Practice Address - Street 2:397 LITTLE NECK RD STE 100
Practice Address - City:VA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452
Practice Address - Country:US
Practice Address - Phone:757-470-5570
Practice Address - Fax:757-227-3377
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01108403542086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
970025366OtherMEDICARE RAILROAD
970025366OtherMEDICARE RAILROAD