Provider Demographics
NPI:1841315678
Name:WELLS, WILLIE L (MD)
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:L
Last Name:WELLS
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 902
Mailing Address - Street 2:
Mailing Address - City:BRUCE
Mailing Address - State:MS
Mailing Address - Zip Code:38915
Mailing Address - Country:US
Mailing Address - Phone:662-983-2151
Mailing Address - Fax:662-983-7151
Practice Address - Street 1:407 EAST CALHOUN ST
Practice Address - Street 2:
Practice Address - City:BRUCE
Practice Address - State:MS
Practice Address - Zip Code:38915
Practice Address - Country:US
Practice Address - Phone:662-983-2151
Practice Address - Fax:662-983-7151
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09661207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B31099Medicare UPIN