Provider Demographics
NPI:1578855466
Name:WELLS, STACEY MAXINE (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:MAXINE
Last Name:WELLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:STACEY
Other - Middle Name:M
Other - Last Name:FULTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-0000
Mailing Address - Fax:
Practice Address - Street 1:1315 ST JOSEPH PKWY STE 1400
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-8237
Practice Address - Country:US
Practice Address - Phone:832-617-0319
Practice Address - Fax:281-727-3490
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ2410208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX345428204Medicaid
TX345428204Medicaid