Provider Demographics
NPI:1568567287
Name:WELLS, JASON EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:EDWARD
Last Name:WELLS
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 1:900 ELMGROVE ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-6236
Mailing Address - Country:US
Mailing Address - Phone:585-426-4100
Mailing Address - Fax:585-453-1462
Practice Address - Street 1:900 ELMGROVE ROAD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-6236
Practice Address - Country:US
Practice Address - Phone:585-426-4100
Practice Address - Fax:585-453-1462
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236925208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMDJ047OtherPREFERRED CARE
NYP020236925OtherBLUE SHIELD OF ROCHESTER
NY02671121Medicaid
P010236925OtherEXCELLUS BLUE CHOICEE
7783666OtherAETNA US HEALTHCARE