Provider Demographics
NPI:1750316337
Name:WELLOCK, MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:WELLOCK
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 1:155 E WARNER RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3082
Mailing Address - Country:US
Mailing Address - Phone:480-649-6600
Mailing Address - Fax:480-649-6700
Practice Address - Street 1:155 EAST WARNER ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295
Practice Address - Country:US
Practice Address - Phone:480-649-6600
Practice Address - Fax:480-649-6700
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1124098Medicaid
WA8868890OtherGROUP PTAN, W OLY FAM MED
WA1225257363OtherGRP NPI, W OLY FAM MED
WA1225257363OtherGRP NPI, W OLY FAM MED
WA1124098Medicaid