Provider Demographics
NPI:1861490740
Name:WELLER, DONALD A (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:A
Last Name:WELLER
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 1:991 MEDICAL PARK DR STE 203
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-8728
Mailing Address - Country:US
Mailing Address - Phone:606-759-5157
Mailing Address - Fax:606-759-5582
Practice Address - Street 1:991 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-8764
Practice Address - Country:US
Practice Address - Phone:606-759-5157
Practice Address - Fax:606-759-5582
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34725207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64001709Medicaid
KYH96431Medicare UPIN
KY00127001Medicare ID - Type UnspecifiedMEDICARE NUMBER