Provider Demographics
NPI:1962459313
Name:WELLS, EVELYN R (MD)
Entity Type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:R
Last Name:WELLS
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 1:17 CLYDESDALE CT
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4902
Mailing Address - Country:US
Mailing Address - Phone:732-241-1805
Mailing Address - Fax:
Practice Address - Street 1:1945 CORLIES AVE
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4859
Practice Address - Country:US
Practice Address - Phone:732-776-4203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2021-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07405300207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8895708Medicaid
NJ8895708Medicaid