Provider Demographics
NPI:1710151980
Name:WELLING, BLAKE G (MD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:G
Last Name:WELLING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4403 HARRISON BLVD
Mailing Address - Street 2:#1815
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3339
Mailing Address - Country:US
Mailing Address - Phone:801-732-5900
Mailing Address - Fax:801-217-2327
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:#1815
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3339
Practice Address - Country:US
Practice Address - Phone:801-732-5900
Practice Address - Fax:801-217-2327
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT973449171205207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT00011969OtherPTAN
UT000011969Medicare PIN