Provider Demographics
NPI:1558478768
Name:WELLINGTON, MICHAEL C (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:C
Last Name:WELLINGTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:ADAMS
Mailing Address - State:MA
Mailing Address - Zip Code:01220-2105
Mailing Address - Country:US
Mailing Address - Phone:413-743-4979
Mailing Address - Fax:
Practice Address - Street 1:555 HUBBARD AVE
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-3876
Practice Address - Country:US
Practice Address - Phone:413-442-2848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2407152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0320676Medicaid
MAT59186Medicare UPIN
MA140058Medicare ID - Type Unspecified