Provider Demographics
NPI:1821285610
Name:WELLER, MICHAELA PUNO (MD)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:PUNO
Last Name:WELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2742 BLACKMAN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9016
Mailing Address - Country:US
Mailing Address - Phone:517-795-1671
Mailing Address - Fax:
Practice Address - Street 1:3855 COOPER ST
Practice Address - Street 2:CHARLES EGELER RECEPTION & GUIDANCE CENTER
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-7547
Practice Address - Country:US
Practice Address - Phone:517-780-5741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010751522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry