Provider Demographics
NPI:1588190847
Name:WELLER, CLAYTON TARRANT (MD)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:TARRANT
Last Name:WELLER
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 1:500 S PRESTON ST RM 305
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1702
Mailing Address - Country:US
Mailing Address - Phone:502-852-8696
Mailing Address - Fax:
Practice Address - Street 1:5353 REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6015
Practice Address - Country:US
Practice Address - Phone:912-819-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA97231207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program