Provider Demographics
NPI:1619958816
Name:WELLS, THEODORE VON JR (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:VON
Last Name:WELLS
Suffix:JR
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 1:6000 N BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-5102
Mailing Address - Country:US
Mailing Address - Phone:716-834-6152
Mailing Address - Fax:716-834-5755
Practice Address - Street 1:6000 N BAILEY AVE
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-5102
Practice Address - Country:US
Practice Address - Phone:716-834-6152
Practice Address - Fax:716-834-5755
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194653207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000524945009OtherBC/BS
NY2309846OtherIHA
NY00010305402OtherUNIVERA
NY01772027Medicaid
NY2309846OtherIHA
NYDD4212Medicare PIN
NY01772027Medicaid