Provider Demographics
NPI:1356384507
Name:WELLIVER, TODD ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:ALAN
Last Name:WELLIVER
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:PO BOX 211118
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33421-1118
Mailing Address - Country:US
Mailing Address - Phone:561-337-4336
Mailing Address - Fax:561-337-6955
Practice Address - Street 1:13005 SOUTHERN BLVD
Practice Address - Street 2:SUITE 233
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9206
Practice Address - Country:US
Practice Address - Phone:561-337-4336
Practice Address - Fax:561-337-6955
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92061207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI29408Medicare UPIN
161372Medicare ID - Type Unspecified