Provider Demographics
NPI:1831482454
Name:WELLS, MICHAEL JASON (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JASON
Last Name:WELLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 COMMERCE CROSSINGS DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:4003 KRESGE WAY STE 410
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4652
Practice Address - Country:US
Practice Address - Phone:502-893-7462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46561207Q00000X
FLME1138752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100263700Medicaid