Provider Demographics
NPI:1184787046
Name:WELLS, CARLA SUZANNE (MD)
Entity type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:SUZANNE
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 1:4050 BARRANCA PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-1723
Mailing Address - Country:US
Mailing Address - Phone:949-559-1911
Mailing Address - Fax:949-559-4071
Practice Address - Street 1:4050 BARRANCA PKWY STE 200
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-1723
Practice Address - Country:US
Practice Address - Phone:949-559-1911
Practice Address - Fax:949-559-4071
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80278207V00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G802780Medicaid
CAG10887Medicare UPIN
CAWG80278AMedicare ID - Type Unspecified