Provider Demographics
NPI:1932250875
Name:WELLER, GLEN E (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:E
Last Name:WELLER
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 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:7 DEYE LN
Practice Address - Street 2:
Practice Address - City:EASTSOUND
Practice Address - State:WA
Practice Address - Zip Code:98245-8578
Practice Address - Country:US
Practice Address - Phone:360-376-2561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAW9618250207R00000X
WAMD00019903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8433708Medicaid
WAG8872572Medicare PIN
WAG8809559Medicare PIN
WAE71747Medicare UPIN
WAG001046118Medicare PIN
WA8433708Medicaid