Provider Demographics
NPI:1245294214
Name:JACOBSON, WELLS C (MD)
Entity type:Individual
Prefix:
First Name:WELLS
Middle Name:C
Last Name:JACOBSON
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 1:36 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4105
Mailing Address - Country:US
Mailing Address - Phone:860-646-0188
Mailing Address - Fax:860-645-9573
Practice Address - Street 1:36 HAYNES ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4105
Practice Address - Country:US
Practice Address - Phone:860-646-0188
Practice Address - Fax:860-645-9573
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022276207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001222769Medicaid
D02573Medicare UPIN
CT001222769Medicaid
200000396Medicare ID - Type Unspecified