Provider Demographics
NPI:1720183874
Name:WELLING, LARRY RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:RAY
Last Name:WELLING
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 1:3451 N BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2357
Mailing Address - Country:US
Mailing Address - Phone:505-566-1915
Mailing Address - Fax:505-566-1918
Practice Address - Street 1:3451 N BUTLER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-566-1915
Practice Address - Fax:505-566-1918
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2000-308207P00000X, 208D00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA2516Medicaid
NMA2516Medicaid
C51390Medicare UPIN