Provider Demographics
NPI:1659504504
Name:WELLS, VALENCIA ROBERTSON (OD)
Entity Type:Individual
Prefix:DR
First Name:VALENCIA
Middle Name:ROBERTSON
Last Name:WELLS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35203-4108
Mailing Address - Country:US
Mailing Address - Phone:205-328-1744
Mailing Address - Fax:205-328-4270
Practice Address - Street 1:2014 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35203-4108
Practice Address - Country:US
Practice Address - Phone:205-328-1744
Practice Address - Fax:205-328-4270
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-26
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-C08-TA-828152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP01303269OtherRAILROAD MEDICARE PTAN
AL152614Medicaid
AL102I410055OtherPTAN
ALP01303269Medicare PIN
AL102I410055Medicare PIN