Provider Demographics
NPI:1952358426
Name:WELLISH, KENT L (MD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:L
Last Name:WELLISH
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 1:2110 E FLAMINGO RD
Mailing Address - Street 2:#210
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5190
Mailing Address - Country:US
Mailing Address - Phone:702-733-2020
Mailing Address - Fax:702-794-2797
Practice Address - Street 1:2110 E FLAMINGO RD
Practice Address - Street 2:#210
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5190
Practice Address - Country:US
Practice Address - Phone:702-733-2020
Practice Address - Fax:702-794-2797
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7032207W00000X
CAG74385207W00000X
AZ21433207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV180023250OtherRAILROAD MEDICARE
NV002019599Medicaid
NV002019599Medicaid
NVV37660Medicare ID - Type Unspecified