Provider Demographics
NPI:1912000332
Name:WELLMAN, JACQUELINE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:L
Last Name:WELLMAN
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 1:67 COOLIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-1127
Mailing Address - Country:US
Mailing Address - Phone:508-393-9292
Mailing Address - Fax:
Practice Address - Street 1:157 UNION ST
Practice Address - Street 2:MARLBOROUGH HOSPITAL
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-1228
Practice Address - Country:US
Practice Address - Phone:774-261-0177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA509942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAFX9902OtherMA MEDICARE
MAC 57296Medicare UPIN