Provider Demographics
NPI:1598731531
Name:WELLES, RICHARD V (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:V
Last Name:WELLES
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 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 670
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-340-8950
Mailing Address - Fax:585-442-3824
Practice Address - Street 1:84 CANAL ST
Practice Address - Street 2:
Practice Address - City:BIG FLATS
Practice Address - State:NY
Practice Address - Zip Code:14814-0448
Practice Address - Country:US
Practice Address - Phone:607-301-4141
Practice Address - Fax:607-301-4140
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199166-12084N0400X
NY1991662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00968552Medicaid
C30426Medicare UPIN