Provider Demographics
NPI:1841477783
Name:WELLER, BRIAN LEE (OD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LEE
Last Name:WELLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:915 W GREEN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-1724
Mailing Address - Country:US
Mailing Address - Phone:269-945-3866
Mailing Address - Fax:269-945-9388
Practice Address - Street 1:915 W GREEN ST STE 101
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1724
Practice Address - Country:US
Practice Address - Phone:269-945-3866
Practice Address - Fax:269-945-9388
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004465152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN34040059Medicare PIN