Provider Demographics
NPI:1588665822
Name:WELLMAN, CYNTHIA L (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:L
Last Name:WELLMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805
Practice Address - Country:US
Practice Address - Phone:260-373-6070
Practice Address - Fax:260-373-6704
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039378A2083P0011X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100378040AMedicaid
OH0425810Medicaid
IN040014982Medicare PIN
IN151060DMedicare PIN
IN047930NNMedicare PIN
IN040009395Medicare PIN
ININ1333014Medicare PIN